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Headaches Associated with Exertion

(as it appeared in NHF Head Lines)

By Edmund Messina, MD
Medical Director
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 with exertion:

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, etc.

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 your physician.