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Headache in Athletes March 2011

Headache in Athletes March 2011. Kevin deWeber, MD, FAAFP Director, Sports Medicine Fellowship USUHS. Objectives. Describe headache types see in those who exercise Outline characteristics of life-threatening conditions that can cause headaches

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Headache in Athletes March 2011

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  1. Headache in AthletesMarch 2011 Kevin deWeber, MD, FAAFP Director, Sports Medicine Fellowship USUHS

  2. Objectives • Describe headache types see in those who exercise • Outline characteristics of life-threatening conditions that can cause headaches • Highlight unique features in treatment of headaches in athletes

  3. Prevalence of headache in athletes • 30% of adolescents (13-15) w/ exertional HA • Cephalalgia 2009 • 36% of college athletes (3% w/ migraines) • Br J Sports Med 1994; Headache 2002 • 36% of distance runners • W V Med J 1999 • 50% of Aussie footballers reported HA

  4. Consequences of Exertional HA • Apprehension --> decreased performance • Limitation of activity • Treatment medicines --> performance

  5. Categories of HA in athletes • Migraines (some are triggered by exertion) • Traumatic HA • Primary Exertional Headache (EH) • No underlying cause known • Secondary EH (due to underlying conditions) • Intracranial hemorrhage, mass lesions, systemic conditions, medications, etc. • Cervicogenic EH

  6. Sport and exercise headache: part 2. diagnosis and classification. Br J Sports Med 1994

  7. Etiology of Exertional Headache • 10-43% have underlying intracranial pathology

  8. Neurology referral clinic: 10% of patients with exertional headaches had an underlying organic cause • 3% Arnold-Chiari malformation • 2% Platybasia • 1% basilar impression • 2% subdural hematoma • 2% brain tumor Rooke ED. Benign exertional headache. Med Clin North Am 1968

  9. Neurology referral clinic, 11 pts:18% (2) of EH were from subarachnoid hemorrhage • 82% were primary (benign) • J Headache Pain 2008

  10. Neurology referral clinic: 43% of 28 patients with exertional HA had underlying pathology • 35% subarachnoid hemorrhage • 4% metastatic breast cancer • 4% pansinusitis Pascual J et al. Cough, exertional, and sexual headaches: an analysis of 72 benign and symptomatic cases. Neurology 1996

  11. Evaluation ofExercise Induced Headache • First objective is to rule out ominous etiologies • Subarachnoid hemorrhage, cerebral aneurysm, Arnold-Chiari malformation, neoplasm, CNS infection, venous sinus stenosis

  12. Headache “Red Flags” • Abrupt, severe onset (“thunderclap” onset) • Loss of consciousness/confusion • Stiff neck, meningeal signs • Change in previously existing HA character • Onset of HA after age 50 • HA associated with head/neck trauma • Neurologic deficits or papilledema • Nocturnal onset/awakening • Increasingly severe over several days

  13. Headache “Red Flags” (cont.) • HA increases in severity with lying down • HA is constant and progressive • HA occurs exclusively in one region • History of cancer or HIV infection • Seizures

  14. Evaluation of the acute, severe headache

  15. Evaluation of worrisome HA • Labs • CBC, Chemistry, BUN/Cr, ESR • Neuroimaging • CT w/ contrast or MRI • Consider MRA of intracranial vasculature • Consider LP for CSF analysis • Blood, cells, pressure, culture

  16. Clinical Case A 52 yo healthy female was at her usual jazzercize class 2 d/a when she notes onset of acute HA on left side of her head. It has pounding quality, is moderately severe, and associated with partial visual loss on right visual field. HA has lessened to 1/10, but visual loss persists. ROS: No other sxs PMH: h/o migraines Exam: visual acuity 20/20 but with patchy visual field deficit. Neuro exam is o/w normal.

  17. Intracranial Hemorrhage • Most common atraumatic cause in athletic population is Subarachnoid Hemorrhage • Majority due to aneurysm • Precipitating factor in athletics is elevated blood pressure • Classic presentation = explosive HA, neck stiffness, photophobia, collapse • “Worst headache I’ve ever had” • “thunderclap headache”

  18. Intracranial Hemorrhage:Management • Take athlete immediately to ED • CT scan, LP if negative • Neurosurgical referral

  19. Mass lesion headache • Usually starts mild and worsens slowly • Occasionally associated with neuro deficit • Risk factor: HA that begins after age 50 • Risk factor: HA located always in one spot • May have symptoms of increase ICP

  20. Mass lesion headache: usually related to increased intracranial pressure • Pain during cough, sneeze, strain, bending forward, and/or sexual orgasm • Rapid onset; usually bilateral but distribution variable • Severe pain for a few minutes that fades to dull ache lasting up to 24 hours • Up to 25% of patients with Valsalva-induced HA have intracranial lesion • CT or MRI indicated

  21. Exercise-induced headache from systemic conditions • Hypoglycemia • Hypertension • Dehydration • Sinus disease • Hyperthermia • Pheochromocytoma • Cardiac ischemia (“cardiac cephalgia”)

  22. Medication-relatedexercise-induced headache • Thermogenic (weight loss) aids • Anabolic steroids • Stimulants

  23. Exercise Induced Migraine • Short periods of vigorous activity • Cycling, sprinting, swimming, weightlifting • Unilateral, severe, throbbing / pounding, preceded by aura • +/- nausea and vomiting • +/- phono-/photo-phobia • Often incapacitating

  24. Trauma Induced Migraine • Terrell Davis in Superbowl 32 in 1998 • Migraine from kick to the head

  25. Migraine headache:Abortive treatment • Acetaminophen/NSAID’s work in a few • Specific abortive meds needed in most • Triptans (5-HT1 agonists) • Ergotamine agents • Antiemetics • Butorphanol nasal spray • Intranasal lidocaine 4% drops

  26. Migraine headache: Abortive treatment (cont.) • Triptans are tx of choice in athletes if unresponsive to analgesics • Less sedation than with most other meds • Rapid onset • Multiple options available • Sumatriptan (SC, oral, nasal spray) • Rizatriptan (oral) • Zolmitriptan (oral) • Naratriptan (oral)

  27. Migraine headache: Abortive treatment (cont.) • Side effects of Triptans • Somnolence, atypical pain, dizziness • Rest in quiet, dark room is helpful • Repeat prn as indicated • Return to play is possible if HA aborted • Contra-indications • CAD, uncontrolled HTN, Prinzmetal’s angina

  28. Migraine headache:Abortive treatment (cont.) • Other meds effective but more side-effects • Dihydroergotamine (nasal, SC, IV, IM) • Nausea, vomiting, chest pain, tachycardia • Prochlorperazine (IM, IV) • Sedation, blurred vision, dizziness • Combination meds (Fiorinal, Midrin) • Sedation • Opiates (butorphanol nasal) • Sedation; overuse risk

  29. Migraine headache:Prophylaxis • Indications • More than 1-2 HA’s/month • HA’s not responsive to abortive treatment • HA’s so severe that they are disabling • Takes several weeks to see benefit • Start at low dose (to avoid side effects) and titrate up • 6 month trial before trying another agent

  30. Migraine headache:Prophylactic meds with relatively low side effect profiles for athletes • Naproxen 500 mg QD • Excellent choice if effective • Vitamin B2 (riboflavin) 200 mg BID • Some decent evidence of effectiveness • Verapamil 240 mg QD • Not very effective, but well-tolerated if it works • Fluoxetine 20-40 mg QD • Not very effective, but well-tolerated if it works

  31. Migraine headache:Prophylactic meds with higher side effect profiles but quite effective • Nortriptyline - titrate up from 10 QHS • Watch for sedation, blurred vision • Beta-blockers - effective, BUT: • Banned by in many sports • Exercise intolerance common • Valproex, topiramate, • Gabapentin, methysergide • Effective, but use only if in a pinch due to side effects

  32. Primary (Benign) Exertional Headache • Should be a diagnosis of exclusion

  33. Primary exertional headache • Precipitated by prolonged exercise • Develops during or after exercise • Running, swimming, cycling, skiing most often implicated • Intensity builds as exercise continues • Etiology: ? Cerebrovascular dilation • Tends to be bilateral and pulsating • Often with migrainous symptoms • Last 5 min to 2 days • Not due to underlying disorder

  34. Primary exertional headache • Comorbidity with migraine common • 40-50%

  35. Primary exertional headache:Workup • Perform CT or MR imaging to r/o secondary causes (10-43%) • SAH most common

  36. Primary exertional headache:Treatment and prevention • Acute Treatment • NSAID • Triptans if migrainous • Consider prophylactic meds if recurrent • Beta-blockers • Indomethacin 50-150 mg/day

  37. Cervicogenic EH“Weight Lifter’s Headache” • A variant of benign exertional HA • Referred pain from structures in neck • Begins abruptly during or immediately following activities involving straining • Tension HA-like quality • Usually posterior, radiates anteriorly • Lasts seconds to minutes • May be followed by diffuse, dull HA for hours

  38. Cervicogenic EH:Treatment • Ice • Analgesics • Massage • Physical therapy modalities • Manipulation

  39. Altitude Headache • Occurs at altitude >2500 meters in those not acclimatized • Component of Acute Mountain Sickness • Severe -- High Altitude Cerebral Edema • Throbbing, generalized

  40. Altitude Headache:Treatment • Prevention: • Best: acclimatization, gradual climb • Acetazolamide (prevents AMS) • ASA 320 mg daily x3d works (Headache 2001) • Sumatriptan works (Ann Neurol 2007) • Treatment • Descent • Time for acclimatization • NSAIDs

  41. Diver’s headache • Multi-factorial • Hypercapnia • Cold stimuli • Decompression sickness (bad) • Excessive gripping of mouthpiece • Sinus barotrauma • Tight goggles, helmet • Mask squeeze • Getting hit on head by pipe

  42. Post-traumatic Headache types • Intracranial bleed • Chronic muscle contraction • Tension-vascular • Migraine (“footballer’s”) • Dysautonomic cephalgia • Post-concussion syndrome HA • Local nerve entrapment

  43. Post-traumatic Headache:Chronic muscle contraction • May be component of Postconcussion Syndrome • Treat as tension HA

  44. Post-traumatic Headache:“Footballer’s migraine” • Caused by heading ball • Seen in boxers and wrestlers after head impact • Symptoms same as a migraine HA • Abortive tx same as regular migraine • Prophylactic meds not very successful

  45. Post-traumatic Headache: Dysautonomic Cephalgia • Cause: damage to cervical sympathetic fibers in the neck at the time of head injury • Occurs up to months after injury • Severe, unilateral, fronto-temporal • Ipsilateral pupil dilation, sweating, vision changes • Treatment: beta-blockers

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