Migraine headaches are a relatively common problem in the general population, and thus are also prevalent in the athletic population. In athletes, exercise and activity can serve as triggers for a previous migraine condition, or it can cause an isolated issue with headaches directly caused by the exertion itself.
Migraine headaches are a problem that can commonly be seen in the general population. They are known to affect 15% to 29% of the population (15%–20% of men and 23%–29% of women) . About 60% of women report a menstrual relationship to their migraine headaches ; 3% of all children suffer migraines, and the prevalence tends to increase with age. By puberty the rate has increased to 7% to 11% . The peak incidence of migraines tends to occur between the ages of 20 and 40 years in both sexes.
A little less than 10% of migraine sufferers report physical activity as a trigger for their headaches . A study of medical and physical education students conducted in the early 1990s found that 35% of respondents reported that they had experienced at least one episode of exercise-related headache . Throughout the literature, an overall prevalence of approximately 1% of the general population seems to be a more accepted rate of benign exertional headache sufferers [6,7]. Although there are few epidemiologic studies concerning headaches and their relation to exercise, physical activity, and sport, Williams and Nukada [8•] have published a well-recognized study out of New Zealand. They used a questionnaire to identify a group of 129 subjects (67 men and 62 women) who were experiencing sports-related headaches. The subjects were then divided into four subgroups, which included effort-exertion headache (60%), post-traumatic headache (22%), sport-induced migraine (15%), effort migraines (9%), trauma-triggered migraines (6%), and miscellaneous causes (3%). Another study that included 791 National Collegiate Athletic Association (NCAA) Division I men and women basketball players showed that 2.9% of the subjects could be classified by International Headache Society (HIS) guidelines as having migraines (0.9% of men and 4.4% of women). The paper also noted that this NCAA Division I basketball population experienced a smaller prevalence of migraines than the general population, and that whites and blacks showed no statistical difference in their rates of migraine . Because headache definitions and classifications vary, it is difficult to perform and support the findings of any epidemiologic study on the subject.
Definitions and Classifications
The most widely accepted classification for headaches has been set forth by the IHS. They define a migraine as “an idiopathic recurring headache disorder manifesting in attacks that last 4 to 72 hours. Typical characteristics of a headache are unilateral location, pulsating quality, moderate to severe intensity, aggravation by routine physical activity, and association with nausea, photophobia, and phonophobia” . The IHS has put forth specific diagnostic criteria that include at least five attacks lasting 4 to 72 hours, and at least two out of four of the following characteristics: unilateral, throbbing, moderate to severe intensity, or aggravated by routine activity. There also must be at least one of the following associated symptoms: nausea, vomiting, photophobia, or phonophobia. Many headache specialists agree that any episodic bad headache should be considered a migraine by default .
Exertion or effort headache, as described by the IHS, is bilateral, throbbing at onset, and may develop migrainous features in those predisposed to migraine. The duration is 5 minutes to 24 hours. The IHS also goes on to say that the headache may be prevented by avoiding excessive exertion, particularly in hot weather . As one can see when comparing the definitions as set forth by the IHS the two are not mutually exclusive. Thus, when writing of exercise-induced migraines it is difficult not to discuss exertion or effort headaches as well.
There are two widely accepted theories that might explain the mechanism of migraine attacks. The first mechanism implies the presence of an irritable pain generator in the brain stem. When this generator is triggered, the trigeminal nerve releases inflammatory chemicals into the brain. This chemical release then leads to migraine symptoms. The second theory relates to serotonin dysregulation. When a particular stimulus is received, serotonin platelet levels drop, thus causing migraine symptoms . Additional research has shown that there is hyperexcitability of the brain between migraine attacks. This also may be explained by two theories. The first involves mitochondrial dysfunction. One study of migraneurs showed a 50% decrease in incidence of attacks following riboflavin supplementation, which indicates that mitochondrial energy might be enhanced by riboflavin . The second of these theories suggests that the hyperexcitability may be caused by magnesium deficiency. It is thought that 30% of migraine sufferers have low levels of intracerebral magnesium, and that during an attack the magnesium level drops acutely .
Neurotransmitters that influence the intracranial pain pathways include serotonin, peptides, and acetylcholine . There are also vasoactive chemicals in the brain that may influence headaches. Many pharmacologic treatments for headaches take aim at these neurotransmitters and vasoactive agents.
History and Physical Examination
When approaching the patient athlete with migraines, as with any topic in medicine, a good history is essential. Ask when the headaches occur. Is it during physical activity? What types of activity? Does it have to be strenuous? Do they only occur during activity? Is there a previous history of migraines in the patient? In his or her family? What are aggravating and alleviating factors? Do environmental issues contribute? Extreme heat or humidity? Bright sunlight? Exercise at altitude? What medications and herbal supplements is the patient taking? Are any of these known to cause headaches? If brought on by exertion, do the headaches rapidly subside when activity is ceased? What was the age of onset of the attacks? How long do the attacks last? How often do they occur? Are there any other past medical problems that may be contributing?
Physical examination should include, at a minimum, vital signs, general inspection, skin inspection looking for rashes, purpura, hemangioma and café au lait spots, fundoscopic examination, head and spine examination (particularly for trauma), a good neck examination for tension and/or trauma, cardiovascular examination, and an in depth neurologic examination. A study of 103 patients with exertional headaches found that approximately 10% had an organic cause for the pain, thus demonstrating the importance of a good history and physical examination, and perhaps additional testing when appropriate .
Additional Clinical Testing
There are several criteria that might lead to ordering additional neuroradiologic tests. A patient who meets any of the criteria would require a CT scan of the head as a first-line test, and/or an MRI. These criteria include 1) patient reports “the worst headache ever” or “thunderclap headache,” 2) suspicion of cerebellar hemorrhage or infarct, 3) stroke in progress or completed stroke with emergency use of anticoagulants, 4) history and examination suggestive of intracerebral hemorrhage or mass lesion, 5) acute signs of increased intracranial pressure, 6) patients at risk for cerebral abscess, 7) blunt head trauma with signs of increased intracranial pressure, 8) depressed skull fracture, 9) open skull fracture, 10) penetrating head injury, and 11) head injury with Glasgow coma rating below 9 [15•]. Thus, not everyone who presents with migraine or migraine-like headaches needs additional work-up. However, because organic disorders such as pheochromocytoma, Arnold-Chiari malformation, aneurysm, and arteriovenous malformation may all cause headaches of this type, careful screening must be performed to rule out these conditions as well.
If a subarachnoid hemorrhage or cerebral abscess is suspected, then a lumbar puncture is also needed. Cardiac evaluation is indicated in patients over the age of 50 with new-onset headache. Lipton et al.  reported nine cases in which the main symptom or manifestation of myocardial ischemia was physical activity-induced headache. In three of the nine patients, headache was the only symptom. They coined the term “cardiac cephalgia” in describing these patients.
The Exertional Headache-Migraine Spectrum
Effort or exertional headaches are the most common type of headache in athletes [6,17–21]. During these headaches a recognizable pattern has been established. There may be prodromal migraine symptoms initially, including scotomata, photopsia, teichopsia, metamorphopsia, vertigo, aphasia, ataxia, or paresthesias. These symptoms, better known as the “migraine aura,” generally occur 10 to 20 minutes prior to the ensuing headache, and cease before the actual headache occurs. The headache itself tends to be bilateral and throbbing and, by definition, lasts 5 minutes to 24 hours, although 6 hours or less is far more typical. Of course, the key element to these headaches is that they are induced by exertion/effort/exercise, and that they tend to recur with the repetition of these particular triggers.
There are several aggravating factors that have been identified. During the 1968 Olympics in Mexico City (a city that lies at high elevation), Jokl  observed that although the athletes were superiorly conditioned, several of the longer-distance runners experienced exercise-induced headaches. Many experienced severe retro-orbital pain, scotomata, nausea, and vomiting. Circumstances that may have led to this problem were extreme heat and humidity, as well as the high altitude. Other aggravating factors can include bright light, excessive fatigue, dehydration, relative hypoglycemia, and insufficient warm-up before exercise. Meyer and Dalessio  have found that cold and dyspnea are also aggravating factors.
Williams and Nukada [8•] suggested prolonged exertion as another trigger, and theorized that low oxygen tension might be the mechanism. They also concluded from their study that, in their population, effort migraines often began in childhood or adolescence, with the average age of onset being 15 years old.
Maneuvers that increase intracranial pressure (including weight lifting, wrestling, and running) have also been associated with exercise-induced headaches and migraines. When certain maneuvers cause an increase in the cerebral arterial pressure, pain-sensitive venous sinuses at the base of the brain can become dilated . Maximal lifts in weight lifters have been demonstrated to cause systolic blood pressures to reach levels above 400 mm Hg and diastolic pressures above 300 mm Hg .
The same triggers for non–exercise-induced migraines may also be exercise-induced migraine triggers, and include alcohol (especially red wine), monosodium glutamate, aspartame, chocolate, aged cheese, pickled foods, processed meats, cultured dairy products, certain odors, allergies, stress, fatigue, oversleeping, and skipped or missed meals. When a person consumes caffeine on a regular basis, caffeine withdrawal can serve as a headache trigger. Many medications have been associated with migraines as well. Even some medications that are used to treat migraines, when used chronically or overused, can cause headaches themselves. These medications include, but are not limited to, acetaminophen, narcotics, caffeine, ergotamines, and triptans .
Post-traumatic head and neck pain are also causes of the headache spectrum. This holds true whether or not a concussion has occurred. These injuries tend to occur during contact sports such as hockey, football, and lacrosse, but may be seen in any type of athletic event.
A blow directly to the head may cause severe headaches, some of which may have migrainous features (especially nausea and vomiting). Other complications of a blow to the head may include visual disturbances, hemiparesis, change in level of consciousness and impaired memory. When head trauma leads to the diagnosis of concussion, it is imperative to withhold the athlete from exercise and competition until the headache has fully resolved, so as to avoid the risk of a “second-impact syndrome,” which may be catastrophic.
In a paper by Bennett et al. , there were three separate football players on one university team that suffered acute migraine attacks directly following game-associated head trauma. The paper also reports on eight other similar previously reported cases, and that nine out of 11 of these athletes had suffered migraine attacks with subsequent trauma.
Those with a previous history of migraine headaches are more likely to incur sports-induced migraines. Any abnormal stress on the neck during sports, whether from contact, repetitive stress, or equipment, may lead to increased tension within the occipitalis and cervical musculature. This increased tension (or spasm) may lead to headaches which are typically considered tension headaches and often present as a band-like pain from posterior to anterior; however, this pressure might also lead to migrainous-type headaches as well.
Because the headaches that are seen in the athletic population do not always meet a particular definition, and because these headaches often portray features of multiple definitions, including those of benign exertional headache and migraine, my opinion is that these headaches are more easily conceptualized when viewed along a spectrum. When approaching the treatment of this spectrum of headaches, it is important to address and limit all of the factors that influence any of the types of headaches in the entire spectrum.
As the saying goes, “prevention is the best treatment.” There are many ways to limit the occurrence and severity of sports-induced headache attacks. First, good eating habits need to be established. The foods (along with alcohol) that are known to be triggers should be avoided, especially in large quantities. Three to six well-balanced meals a day should be scheduled at regular intervals. Supplementation with riboflavin, 200 mg orally twice daily, and/or magnesium citrate, 200 mg orally twice daily, may also reduce occurrence . Offending allergens and odors need to be limited or avoided. Sleep hygiene is also important. Approximately 8 hours a night of regularly scheduled sleep is generally recommended, although some individuals might find that a different amount of sleep limits their individual headaches better. Athletes should always maintain an appropriate fluid intake as to prevent dehydration. Whenever a patient exercises, proper warm-up is essential. This especially holds true in exertional-headache sufferers. When participating in sports that require maneuvers that increase intracranial pressure, or Valsalva maneuver, the athlete must be trained in appropriate breathing techniques. Because overexertion can also serve as a contributor, it should be avoided whenever possible.
In those patients who cannot prevent the occurrence of these headaches, prophylaxis may be necessary. Prophylaxis may also be necessary if headaches cannot easily be aborted. There was a time when indomethacin was considered the gold standard for prophylaxis of exercise-induced headache. It is still a good option, but because there is such a high degree of individual variance in response to medications, there is not a single gold standard today. Other prophylactic options include all other nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, calcium channel blockers (particularly verapamil hydrochloride and nimodipine), tricyclic antidepressants including amitriptyline, selective serotonin reuptake inhibitors, some monoamine oxidase inhibitors (MAOIs), clonidine hydrochloride, methysergide maleate, and γ-blockers. Take caution in using γ-blockers in athletes because decrease in heart rate and exercise tolerance can occur. Unless the headaches have some migrainous features, some of these treatments will not be appropriate, especially MAOIs, methysergide maleate, and clonidine.
When the headaches are actually occurring, attempts at aborting them may be made. The athlete can be placed in a dark and quite place. Aspirin and NSAIDs are also useful for headache abortion. In some cases, triptans, ergotamines, chlorpromazine hydrochloride, and antiemetics may be appropriate; 100% oxygen via nonrebreather or lidocaine 4% nasal drops may also be tried. Occasionally, narcotics are required for pain relief.
There are also some alternative approaches for the difficult to manage patient. Blumenfeld  concluded that botulinum toxin type A may be an effective and safe prophylactic treatment for a variety of chronic headache types. Another randomized controlled study concluded that acupuncture, as a supplement to medical management, resulted in improvements in headache-related quality of life, and the perception that patients suffered less from headaches .
Other Sports Headaches
External compression headaches from poorly fitting or prolonged wearing of hats and helmets can plague athletes. In a study of helmet-wearing Brazilian police officers , it was found that these headaches often resolved in less than 1 hour of removing the stimulus. Similar headaches may occur in swimmers and divers who wear goggles and masks [29,30].
Any athlete who performs his or her sport at high altitude may be at risk for headaches associated with acute mountain sickness, or high-altitude headaches. These headaches can be prevented with adequate hydration, as well as prophylaxis with aspirin and acetazolamide.
Headaches in the athletic population are a common problem. Exercise can be the sole cause of the headache, or serve as a trigger for a chronic headache patient. Because it is difficult for physicians to agree on exact classification and definition of different headache syndromes, it may be best to view sport and exercise-induced headaches as a spectrum. Athletes' headaches deserve a unique view that takes into consideration the stresses that a particular sport may place on the body. Careful evaluation of history and physical examination can help direct further work-up to find the approximately 10% of athletic migraines that have an organic cause. Treatment of the spectrum of headaches should address prevention, abortion, and in appropriate cases, prophylaxis.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
1. Stewart W, Lipton R, Celentano D: Prevalence of migraine headache in the United States: relation to age, income, race, and other sociodemographic factors.JAMA
2. Edelson RN: Menstrual migraine and other hormonal aspects of migraine.Headache
3. Scheller J: The history, epidemiology and classification of headaches in childhood.Semin Pediatr Neurol
4. Chabriat H, Danchot J, Michel P, et al.
: Precipitating factors of headache. A prospective study in a national control-matched survey in migraneurs and nonmigraneurs.Headache
5. Williams ST, Nukada H: Sport and exercise headache: Part 1. Prevalence among university students.Br J Sports Med
1994 Jun, 28
6. McCrory P: Recognizing exercise-related headache.Phys Sportsmed
7. Rasmussen B, Olsen J: Symptomatic and non-symptomatic headache in a general population.Neurology
8.• Williams ST, Nukada H: Sport and exercise headache: Part 2. Diagnosis and classification.Br J Sports Med
One of the landmark studies on the topic. It also provides a good classification system for this spectrum of headaches.
9. Kinart CM, Cuppett MM, Berg K: Prevalence of migraines in NCAA Division I male and female basketball players.Headache
10. International Headache Society: Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Headache Classification Committee of the International Headache Society.Cephalgia
1988, 8(Suppl 7)
11. Lane JC: Migraine in the athlete.Semin Neurol
12. Schoenen J, Jacqy J, Lenaerts M: Effectiveness of high-dose riboflavin migraine prophylaxis.Neurology
13. Welch K: Synthesis of mechanisms.
Boston, MA: 49th Annual Meeting of the American Academy of Neurology. April 12–19, 1997.
14. Rooke ED: Benign exertional headache.Med Clin North Am
15.• Diamond S: Managing migraines in active people.Phys Sportsmed
Provides an excellent chart on pharmacologic treatments, as well as their side effects.
16. Lipton R, Lowenkopf T, Bajwa Z, et al.
: Cardiac cephalgia: a treatable form of exertional headache.Neurology
17. Jokl E: Olympic medicine and sports cardiology.Ann Sports Med
18. Dalessio DJ: Effort migraine, editorial.Headache
19. Massey EW: Effort headache in runners.Headache
20. Seelinger DF, Coin GC, Carlow TJ: Effort headaches with cerebral infarction.Headache
21. Lambert RW, Burnet DL: Prevention of exercise induced migraine by quantitative warm-up.Headache
22. Meyer JS, Dalessio DJ: Headache associated with chemical toxins, systemic infections, and metabolic disorders (toxic vascular headache).
In Wolff's Headache and Other Head Pain, edn 6. Edited by Dalessio DJ Silberman SD. New York: Oxford University Press; 1993:209–234.
23. MacDougall JD, Tuxen D, Sale DG, et al.
: Arterial blood pressure response to heavy resistance exercise.J Appl Physiol
24. Diener HC, Katsarava Z: Medication overuse headache.Curr Med Res Opin
25. Bennett DR, Fuenning SI, Sullivan G, Weber J: Migraines precipitated by head trauma in athletes.Am J Sports Med
26. Blumenfeld A: Botulinum toxin type A as an effective prophylactic treatment in primary headache disorders.Headache
27. Coeytaux RR, Kaufman JS, Kaptchuk T, et al.
: A randomized controlled trial of acupuncture for chronic daily headache.Headache
28. Krymchantowski A, Barbosa JS, Cvaigman M, et al.
: Helmet-related external compression headache among police officers in Rio de Janeiro.Med Gen Med
29. Turner J: Exercise-related headache.Curr Sports Med Rep
30. Cheshire W, Ott MC: Headache in divers.Headache