Exercise Related Headache
The connection between headache and exercise was noted circa 300 B.C. by Hippocrates:
"One should be able to recognize those who have headaches from gymnastic exercises or running or walking or hunting or any other unseasonable labor."
The main categories of headache include tension headache and migraine, both of which can occur in athletes. This review concentrates on a headache syndrome that is unique to sports: exertional headache.
Benign exertional headache has been recognized as a separate entity for more than 60 years. Tinel described severe but transient headaches following exercise in 1932. Since then, these headaches have been reported with exercises such as weight lifting and wrestling.
Recent studies have revealed that straining (Valsalva maneuver) precipitates the acute onset of severe throbbing pain, usually occipital (lasting only a few seconds to a few minutes). The headache then settles to a dull ache lasting 4 to 6 hours. In subsequent weeks or months, the headache recurs with exertion. The patient has no history of migraine and a normal neurologic exam.
Before labeling an athlete with benign exertional headache, it is important to rule out the possibility of intracranial pathology suggested by the following symptoms:
• sudden onset of severe headache
• headache increasing over a few days
• new or unaccustomed headache
• persistently unilateral headaches
• atypical headache or a change in usual pattern of headache
• headaches that wake the patient during the night or early morning
• chronic headache with localized pain
• stiff neck or other signs of meningismus
• systemic symptoms (e.g., weight loss, fever, malaise)
• focal neurologic symptoms or signs
• local extracranial symptoms (e.g., sinus, ear, or eye disease)
The clinical features of exercise-related headaches are contrasted with posttraumatic headaches in the accompanying table.
Once the diagnosis is established, the treatment is primarily reassurance due to the benign, self-limited nature of the condition. Analgesics may be used.
(McCrory P. Recognizing exercise-related headache. Physician & Sports Medicine 1997;25(2):33-43)
Headache Type
Exertional Posttraumatic
Onset Acute Variable
Duration Hours Variable
Pain Quantity Throbbing Throbbing
Tend to Recur Yes Yes
Migraine History No No
Aggravated by
Neck Movement No Sometimes
Normal Physical Exam Yes No
Normal Tests Yes No
Comment: Headaches have always been, for me, a convoluted conundrum to solve. A ten-year-old boy I once saw had all the features of psychogenic headache - he turned out to have a brain tumor. I sympathize with school nurses who must decide which students to refer. I can offer no simple guidelines. This type of clinical challenge is a good example of why RN’s and not paraprofessionals are essential to smooth school health room functioning. -R.A.