Headache in Athletes

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Headache in Athletes
Kevin deWeber, MD Primary Care Sports Medicine
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Objectives

• Describe headache types see in athletes
• Outline characteristics of life-threatening
  conditions that can cause headaches
• Review treatments for headaches
• Highlight unique features in treatment of
  headaches in athletes

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Prevalence of headache in athletes

• Up to 36 of athletes report moderate or severe
  headaches
• HAs may lead to
• limitation of activity (during acute treatment)
• apprehension --gt decreased performance
• treatment medicines --gt performance

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Broad categories ofHeadache in athletes

• Exercise-induced HA
• Non-exercise-induced HA
• There may be some overlap
• e.g. patient has migraines in off-season but gets
  them more frequently during play

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Types of exercise-induced HA

• Exercise-induced HA due to underlying
  conditions
• Mass lesions
• Systemic conditions
• Medications
• HAs purely from exercise
• Intracranial hemorrhage
• Weightlifters HA
• Acute effort migraine
• Benign exertional HA

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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

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Mass lesion Headache with 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
  intracranial structural lesion
• CT or MRI indicated

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Headache with increased intracranial
pressureTreatment

• (after mass lesion is ruled out)
• Activity modification to whatever degree is
  practical
• Indomethacin 25-50 mg TID
• Other NSAIDs

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Exercise-induced headache from systemic conditions

• Hypoglycemia
• Hypertension
• Dehydration
• Sinus disease
• Hyperthermia
• Pheochromocytoma
• Cardiac ischemia (walk headache)

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Medication-relatedexercise-induced headache

• Thermogenic (weight loss) aids
• Anabolic steroids
• Stimulants

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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 Ive ever had

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Intracranial HemorrhageManagement

• Take athlete immediately to ED
• CT scan
• Neurosurgical referral

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Weight Lifters Headache

• A variant of benign exertional HA
• In anaerobic activities involving straining
• Begins abruptly during or immediately following
  the activity
• Referred pain from ligaments and muscles in neck
• Usually posterior throbbing
• Lasts seconds to minutes
• May be followed by diffuse, dull HA for hours

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Weight Lifters HeadacheTreatment

• Analgesics, NSAIDs
• Massage
• Physical therapy modalities

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Acute Effort Migraine

• Short periods of vigorous activity
• Cycling, sprinting, swimming, weightlifting
• Unilateral, severe, throbbing / pounding,
  preceded by aura
• Accompanied by nausea and vomiting
• Treatment same as non-exercise-induced migraine
  (later discussion)

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Benign exertional headache

• Should be a diagnosis of exclusion

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Benign exertional headache

• Precipitated by any form of exercise
• Running, swimming, cycling, skiing most often
  implicated
• More common in men
• Develops after exercise is well underway
• Intensity builds as exercise continues
• Tends to be diffuse and throbbing
• Last up to 6 hours after cessation of exercise

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Benign exertional headacheTreatment and
prevention

• Effectively treated with NSAIDs
• Naprosyn 250-500 mg
• Indomethacin 25-50 mg
• /- acetaminophen
• Prevented if meds given 30-60 minutes before
  exercise

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Evaluation ofexercise-induced headache

• First objective is to rule out ominous etiologies
  
• Subarachnoid hemorrhage, cerebral aneurysm,
  Arnold-Chiari malformation, neoplasm, CNS
  infection

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Worrisome headache characteristics

• Abrupt, severe onset (thunderclap onset)
• Change in previously existing HA character
• Onset of HA after age 50
• HA associated with head/neck trauma
• Associated neurologic deficits or papilledema
• Nocturnal onset

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Worrisome headache characteristics (cont.)

• HA increases in severity with laying down
• HA is constant and progressive
• HA occurs exclusively in one region
• History of cancer or HIV infection
• Associated loss of consciousness or confusional
  state

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Evaluation of the acute, severe headache
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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

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Non-exercise-induced headaches in athletes

• Tension HA
• Migraine HA
• Mixed HA
• Cluster HA
• Cervical spine-related HA
• Altitude HA
• Divers HA
• Post-traumatic HA

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Tension headacheSymptoms

• Gradual onset, worsening as day progresses
• May begin focal becomes diffuse
• Band-like, pressure quality
• Constant may throb at peak intensity
• May have mild photophobia/phonophobia
• Worsened by exertion
• Mixed HA components of migraine and tension HA
  together

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Tension headacheNon-Pharmacologic treatment

• Address contributing factors
• Stress, anxiety, depression
• Physical therapy for cervical stretching
• Biofeedback
• Stress management techniques

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Tension headachePharmacologic treatment

• Acetaminophen and NSAIDs effective in most
  patients
• Muscle relaxant if muscle tension a feature
• Isometheptine (Midrin) if mixed headache
• Instruct patients to avoid daily use
• Avoids analgesic withdrawal headache

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Chronic tension headache

• Definition more than 15 HA days a month
• Use prophylactic meds instead
• Nortriptyline - titrate up from 10 mg qHS
• May next try SSRI, bupropion, valproate
• Abortive meds only for intense headaches

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Migraine Headache

• Vascular etiology
• Spasm, dilation, inflammation
• Unilateral usually
• Throbbing usually
• Nausea/vomiting usually present
• Phono-/photophobia usually present
• Moderate to severe intensity
• Occasional aura or neuro signs

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Migraine headacheAbortive treatment

• Acetaminophen/NSAIDs work in a few
• Specific abortive meds needed in most
• Triptans (5-HT1 agonists)
• Ergotamine agents
• Combination meds (many)
• Antiemetics
• Butorphanol nasal spray
• See recent U.S. Headache Consortium recs

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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)

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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, Prinzmetals angina

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Migraine headacheAbortive 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

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Migraine headacheProphylaxis

• Indications
• More than 1-2 HAs/month
• HAs not responsive to abortive treatment
• HAs 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

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Migraine headacheProphylactic meds with
relatively low side effect profiles for athletes

• Naproxen 500 mg QD
• Excellent choice if effective
• Vitamin B2 (riboflavin) 400 mg QD
• 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

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Migraine headacheProphylactic meds with higher
side effect profiles but quite effective

• Nortriptaline - titrate up from 10 QHS
• Watch for sedation, blurred vision
• Beta-blockers - effective, BUT
• Banned by in many sports
• Exercise intolerance common
• Valproex, gabapentin, methysergide
• Effective, but use only if in a pinch due to side
  effects

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Cluster headache

• Occur in clusters of 1-3 month duration, then
  resolve months to years
• Unilateral, retro-orbital or temporal usually
• Sharp, boring, constant pain usually
• Severe, disabling
• Duration 15 min - 3 hours
• Associated with ipsilateral lacrimation, nasal
  congestion, conj. injection, rhinorrhea, facial
  flushing, or sweating

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Cluster headacheTreatment

• Three types
• Abortive tx of acute HA
• Abortive management of episodic clusters
• Long-term prophylaxis

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Cluster headacheAbortive treatment of acute HA

• The sooner, the better
• Oral meds ineffective
• Effective meds
• High-flow O2
• Sumatriptan SC, nasal
• Dihydroergotamine SC, nasal
• Ergotamine sublingual
• Butorphanol nasal

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Cluster headacheAbortive tx of clusters

• Lessens frequency and/or severity of HA
• Administer as long as clusters last
• Effective meds
• Ergotamine (oral) or methysergide AND
• Prednisone 60-80 mg/day taper over 14 days after
  HA frequency decreases

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Cluster headacheProphylaxis of clusters

• Verapamil quite effective
• Valproate
• Lithium carbonate
• Methysergide
• Propranolol
• Amitriptaline

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Cervical Spine Headache

• Suboccipital and unilateral
• Mild to moderate in severity, nagging
• Features
• Pain on awakening, previous neck injury
• Exacerbated by neck movements (extension)
• Neck stiffness
• Treatment PT modalities

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Altitude Headache

• Occurs at altitude gt2500 meters
  in those not acclimatized
• Component of Acute Mountain Sickness
• Severe -- High Altitude Cerebral Edema
• Throbbing, generalized
• Prevention acclimatization, gradual climb,
  acetazolamide
• Treatment descent or time

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Divers headache

• Multi-factorial
• Excessive gripping of mouthpiece
• Sinus barotrauma
• Tight goggles, helmet, mask

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Post-traumatic Headache types

• Intracranial bleed
• Chronic muscle contraction
• Tension-vascular
• Migraine (footballers)
• Dysautonomic cephalgia
• Post-concussion syndrome HA
• Local nerve entrapment

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Post-traumatic HeadacheChronic muscle
contraction

• May be component of Postconcussion Syndrome
• Treat as tension HA

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Post-traumatic HeadacheFootballers 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

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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

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Post-traumatic Headache Local Nerve Entrapment

• Caused by fibrosis around nerve at site of
  previous trauma
• Localized to specific site of nerve
• Treatment may require surgical decompression

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Posttraumatic HeadachePost-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)

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REVIEW
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Up to 10 of patients with exercise-induced
headaches have an intracranial mass lesion
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Evaluation ofexercise-induced headache

• First objective is to rule out ominous etiologies
  
• Subarachnoid hemorrhage, cerebral aneurysm,
  Arnold-Chiari malformation, neoplasm, CNS
  infection

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Worrisome headache characteristics

• Abrupt, severe onset (thunderclap onset)
• Change in previously existing HA character
• Onset of HA after age 50
• HA associated with head/neck trauma
• Associated neurologic deficits or papilledema
• Nocturnal onset

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Worrisome headache characteristics (cont.)

• HA increases in severity with laying down
• HA is constant and progressive
• HA occurs exclusively in one region
• History of cancer or HIV infection
• Associated loss of consciousness or confusional
  state

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Benign exertional headache

• Should be a diagnosis of exclusion

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QUESTIONS?