(as it appeared in NHF
By Edmund Messina, MD
Michigan Headache Clinic
East Lansing, Michigan
Patients will commonly ask me, "Is exercise good for
my headaches or, "Is it dangerous if my headaches get
worse when I exercise?"?"
It's common knowledge that exercise is good for us in general.
People who regularly exercise will sleep better, feel better
and commonly report an overall reduction in their headache
frequency. This is puzzling for people who experience a worsening
of their headaches when they exercise. Other people can actually
start having headache when they exercise or exert themselves.
It's helpful to separate this issue into several categories.
Worsening an existing headache
Most of us who get migraine headaches have experienced worsening
of head pain when we exert ourselves, like running up a flight
of stairs or even bending down to look under the bed. It's
very important to distinguish pre-existing headaches that
are worsened by exertion from headaches which are actually
caused by exertion. This is a very important point. Some of
these conditions may be harmless but others could be due to
dangerous underlying conditions.
Although it is very common for migraine to be worsened by
exertion, it's important to remember that headaches will worsen
in people with increased pressure inside of their head, including
people with brain tumors or blood vessel abnormalities. Blood
vessel abnormalities, such as cerebral aneurysms or arteriovenous
malformations can be quite dangerous. Please don't panic if
you experienced worsening with exertion, it needs to be put
into the perspective of your general history, neurologic examination,
Sudden onset headaches, with
or without exertion:
Headaches which suddenly occur need to be evaluated, as any
new onset headache. In these situations aneurysms and tumors
must be ruled out. Aneurysms are bulging areas in an artery,
which may look like a berry on a stem. A ruptured aneurysm
can cause a lethal bleed around the brain. This is known as
a subarachnoid hemorrhage. Aneurysms may be missed on a conventional
MRI scan or CT scan but they can usually be found on an MRA
(magnetic resonance angiogram). Another blood vessel abnormality
which can cause a sudden headache, is known as an AVM (or
arteriovenous malformation). This is a tangle of blood vessels
that can bleed and be potentially life-threatening.
A thunderclap headache is a very dangerous sign
until proven innocent. Usually these are called "the
worst headache of my life" and reach their maximum pain
in less than a minute. A person who first gets a thunderclap
headache should be evaluated immediately in an emergency room
where an emergency CT scan and lumbar puncture must be performed
in order to examine the spinal fluid for blood. The thunderclap
headache can be caused by a ruptured blood vessel such as
aneurysm or AVM but also by other conditions which need to
be ruled out. This headache should never be ignored and subsequent
testing with MRI and MRA is necessary. It can occur spontaneously
or be provoked by exertion or coughing.
Headaches caused by sexual activity, with or without
exertion, will be discussed below.
Headaches that are provoked by exertion: in other words,
the person doesn't have a headache until they exert themselves.
The headache is actually triggered by some form of exertion.
People with the new onset of exertional headaches generally
need evaluation with a good quality MRI and MRA, looking for
conditions such as tumors or aneurysms. A common cause is
known as the Arnold-Chiari malformation, where the cerebellum,
located at the back of the brain, appears to be forced downward
through the opening at the bottom of the skull. Remember,
if you experience the new onset of exertional headache, you
need to be evaluated by your physician.
Fortunately, most people with exertional headaches have less
frightening explanations. The more benign causes of exertional
headache include primary cough headache, primary exertional
headache and primary headache associated with sexual activity.
These can only be diagnosed if the more frightening causes
can be ruled out.
Primary cough headache is of sudden onset during coughing
or a sudden physical strain. It usually occurs within seconds
of coughing, sneezing or straining. The pain is usually described
as “sharp”, “stabbing” or “splitting”
and can be quite severe in some cases. It usually occurs on
both sides of the head and is felt most intensely in the back
of the head, top of the head or forehead, although it can
also occur in both temples at the same time. Although usually
these headaches last up to about half an hour, Dr. Seymour
Diamond has described cough headaches which lasted for hours
after the event. It's of interest that these headaches are
not accompanied by any other neurological symptoms and there
is no nausea or vomiting. Cough headache usually occurs in
people above the age of 40, so if it occurs in younger people,
they especially need to be evaluated for other causes. Conditions
which imitate primary cough headache include masses in the
back of the brain, such as tumors or the Chiari malformation.
About half of all cough headache cases are due to an abnormality,
so proper testing is very important.
Cough headaches can be prevented by using indomethacin, which
may be useful during bouts of bronchitis or other temporary
periods of repetitive coughing. Needless to say, smokers need
to stop smoking, permanently. Repetitive use of indomethacin
can produce G.I. bleeding, so caution is needed. Most people
don't need to treat these headaches unless they're having
frequent bouts of coughing. Prolonged coughing, needless to
say, needs to be evaluated by a physician.
Primary exertional headache is produced by physical exercise
or strain and usually starts as a throbbing pain on both sides
of the head. Exertion may take the form of prolonged exercise,
strenuous exercise such as lifting weights and other activities
which might cause a red face. About 10% of the general population
may experience exertional headache. They may occur more readily
in high temperature, high humidity, high altitude or after
drinking caffeine or alcohol.
These headaches can begin suddenly, and usually are bilateral.
Some people experience these headaches immediately upon exertion,
others will have to run a few blocks or do a few repetitions
of exercise before they strike. Sometimes the exertional headache
will occur after the completion of physical exertion. These
headaches can last from 5 minutes to 24 hours. Medications
such as propranolol and indomethacin before exercise can sometimes
prevent these attacks, although propranolol can reduce your
exercise tolerance. Again, it is essential to rule out disorders
such as arterial disease or brain masses, especially if the
headaches are one sided.
Headache associated with sexual activity can occur in several
forms (pre-orgasmic and orgasmic). They are more common in
men than women, and patients are often embarrassed to tell
their doctors about this… so don't be shy. They can
occur during sexual intercourse as well as masturbation and
are not necessarily associated with exertion during sex.
Pre-orgasmic headaches often begin as a dull, two-sided headache
which increases with sexual excitement. Orgasmic headache
is more common, beginning abruptly at the moment of orgasm.
Patients usually describe this pain is excruciatingly severe
and throbbing, sometimes associated with nausea and vomiting.
These headaches can last up to three hours. Needless to say,
this may have a long-lasting impact on a person's sex drive
unless it is prevented.
People can experience only the dull type, only the explosive
type or both, although the orgasmic headache accounts for
about 75% of the cases. Only about half of these patients
have pre-existing migraine. The new onset of this headache,
especially if it's a thunderclap headache, requires immediate
evaluation for aneurysm and other causes noted above. If no
obvious dangerous causes are identified, this is a benign
condition and sometimes can be prevented by using anti-inflammatory
medicines before engaging in sexual activity. Over time, this
type of headache will occur less frequently.
A less common type of sexually related headache, perhaps
about 5%, is the so-called postural type. It seemed to be
associated with position, and after it begins it will worsen
with standing or sitting up and be relieved by lying down.
This is not classified with the primary sexual headaches,
it seems to be related to spinal fluid leaks.
In summary, existing headaches, especially migraine,
may worsen with exertion, the most common exception being
tension type headache. Brain disorders can also cause exertional
headaches and careful evaluation is necessary. If you experience
exertional headaches, it's a good idea to discuss it with