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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

Headache in AthletesMarch 2011

Kevin deWeber, MD, FAAFP

Director, Sports Medicine Fellowship

USUHS

objectives
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
prevalence of headache in athletes
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
consequences of exertional ha
Consequences of Exertional HA
  • Apprehension --> decreased performance
  • Limitation of activity
  • Treatment medicines --> performance
categories of ha in athletes
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
slide6

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

etiology of exertional headache
Etiology of Exertional Headache
  • 10-43% have underlying intracranial pathology
neurology referral clinic 10 of patients with exertional headaches had an underlying organic cause
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

neurology referral clinic 11 pts 18 2 of eh were from subarachnoid hemorrhage
Neurology referral clinic, 11 pts:18% (2) of EH were from subarachnoid hemorrhage
  • 82% were primary (benign)
    • J Headache Pain 2008
neurology referral clinic 43 of 28 patients with exertional ha had underlying pathology
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

evaluation of exercise induced headache
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
headache red flags
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
headache red flags cont
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
evaluation of worrisome ha
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
clinical case
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.

intracranial hemorrhage
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”
intracranial hemorrhage management
Intracranial Hemorrhage:Management
  • Take athlete immediately to ED
  • CT scan, LP if negative
  • Neurosurgical referral
mass lesion headache
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
mass lesion headache usually related to increased intracranial pressure
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
exercise induced headache from systemic conditions
Exercise-induced headache from systemic conditions
  • Hypoglycemia
  • Hypertension
  • Dehydration
  • Sinus disease
  • Hyperthermia
  • Pheochromocytoma
  • Cardiac ischemia (“cardiac cephalgia”)
medication related exercise induced headache
Medication-relatedexercise-induced headache
  • Thermogenic (weight loss) aids
  • Anabolic steroids
  • Stimulants
exercise induced migraine
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
trauma induced migraine
Trauma Induced Migraine
  • Terrell Davis in Superbowl 32 in 1998
  • Migraine from kick to the head
migraine headache abortive treatment
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
migraine headache abortive treatment cont
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)
migraine headache abortive treatment cont28
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
migraine headache abortive treatment cont29
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
migraine headache prophylaxis
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
migraine headache prophylactic meds with relatively low side effect profiles for athletes
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
migraine headache prophylactic meds with higher side effect profiles but quite effective
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
primary benign exertional headache
Primary (Benign) Exertional Headache
  • Should be a diagnosis of exclusion
primary exertional headache
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
primary exertional headache35
Primary exertional headache
  • Comorbidity with migraine common
    • 40-50%
primary exertional headache workup
Primary exertional headache:Workup
  • Perform CT or MR imaging to r/o secondary causes (10-43%)
    • SAH most common
primary exertional headache treatment and prevention
Primary exertional headache:Treatment and prevention
  • Acute Treatment
    • NSAID
    • Triptans if migrainous
  • Consider prophylactic meds if recurrent
    • Beta-blockers
    • Indomethacin 50-150 mg/day
cervicogenic eh weight lifter s headache
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
cervicogenic eh treatment
Cervicogenic EH:Treatment
  • Ice
  • Analgesics
  • Massage
  • Physical therapy modalities
  • Manipulation
altitude headache
Altitude Headache
  • Occurs at altitude >2500 meters in those not acclimatized
  • Component of Acute Mountain Sickness
    • Severe -- High Altitude Cerebral Edema
  • Throbbing, generalized
altitude headache treatment
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
diver s headache
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
post traumatic headache types
Post-traumatic Headache types
  • Intracranial bleed
  • Chronic muscle contraction
  • Tension-vascular
  • Migraine (“footballer’s”)
  • Dysautonomic cephalgia
  • Post-concussion syndrome HA
  • Local nerve entrapment
post traumatic headache chronic muscle contraction
Post-traumatic Headache:Chronic muscle contraction
  • May be component of Postconcussion Syndrome
  • Treat as tension HA
post traumatic headache footballer s migraine
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
post traumatic headache dysautonomic cephalgia
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
posttraumatic headache post concussion syndrome
Posttraumatic Headache:Post-Concussion Syndrome
  • HA as part of symptom complex:
    • Dizziness, tinnitus, diplopia, blurred vision, irritability, anxiety, depression, fatigue, sleep disturbance, poor appetite, poor memory, impaired concentration, slowed reactions
  • HA is probably tension type
  • Treat as with chronic tension HA
  • Goes away with time (up to months)
exacerbation of pre existing headache syndromes
Exacerbation of pre-existing headache syndromes
  • Migraines, tension HA, mixed, cluster
  • Treat as usual
review
Review
  • Exertional HA has a significant incidence of underlying pathology
    • 10-43% with pathology
    • Thorough w/u at onset
  • First objective is to rule out ominous etiologies
    • Subarachnoid hemorrhage, cerebral aneurysm, Arnold-Chiari malformation, neoplasm, CNS infection
  • Remember HA “red flags”
headache red flags54
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
headache red flags cont55
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