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Exertional Headache: Uncommon,
Usually Benign, but Worrisome |
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BY MAURY BREECHER
Contributing Writer |
SCOTTSDALE, ARIZ. (ECCC)—
Uncommon and usually benign, exertional headaches nonetheless
require a careful work-up to exclude potentially serious
underlying problems, said Dr. Roger Cady on February 22 at a
Headache Research Summit sponsored by the Diamond Headache
Clinic Research and Education Foundation.
Exertional headaches fall into three categories: physical
exertion, cough, and sexual. Each subtype affects about 1% of
the population.
“The headaches are uncommon but they cause enough distress that
almost every practice will have patients with these particular
types of headaches,” said Dr. Cady, associate director of the
Headache Care Center in Springfield, Mo.
In its classification system, the International Headache Society
(IHS) includes exertional headaches in the section devoted to
headaches unassociated with a structural lesion (Cephalalgia.
2004;24[suppl. 1]:1-160).
The IHS definition of benign exertional headache encompasses
several features, such as onset specifically associated with
exercise; bilateral, throbbing pain that may have migrainous
features; duration of 5 minutes to 24 hours; and is not
associated with any systemic or intracranial disorder.
Most of the knowledge about exertional headache has come from
several hundred cases reported in the literature, said Dr. Cady.
The mean age of onset is 55, and the condition is twice as
common in people older than 40 compared with younger
individuals. Historically, men affected have outnumbered women
by 4:1, but the ratio is changing as women increasingly engage
in physical work. As many as 25% of patients have antecedent
respiratory infection (Med Clin N Am. 1991;75:733-747).
The onset of pain is immediate or within seconds of beginning
the triggering activity. The pain is usually severe and has a
bursting or explosive quality. Two-thirds of patients have
bilateral headache, and the pain can arise in any area of the
head.
Case series have generally been reassuring about the prognosis
of patients with exertional headache but not universally
positive. One of the largest series involved 103 patients with
no evidence in intracranial (Med Clin N Am. 1968;52:801-808).
After 3 years of follow-up, 10 patients had developed
intracranial lesions.
“That is a high incidence of intracranial lesions and
illustrates the point that even though the headaches are benign
and have no underlying cause, the patients have an increased
potential for underlying disease or underlying structural
lesions,” said Dr. Cady. “Patients with this class of headache
almost inevitably will require some type of work-up.”
Of the remaining 93 patients in the series, 30 were
headache-free at 5 years, and 73 were improved or headache-free
at 10 years.
A report on 28 cases of exertional headache showed that 16
patients had primary exertional headache, and 12 had exertional
headache secondary to other causes (Neurology.
1996;46:1520-1524). Ten of the 12 secondary headaches involved
subarachnoid hemorrhage, and one each involved malignancy and
pansinusitis. Patients with primary exertional headache were
substantially younger (24 years of age vs 42 years of age for
patients with secondary headache).
Multiple secondary causes can result in exertional headache,
including migraine, lumbar puncture, chronic obstructive
pulmonary disease, and anabolic steroid use (Cur Treat Options
Neurol. 2002;4:375-381).
The basic approach to treatment of primary benign exertional
headache comprises nonpharmacologic (warm-up before exercise,
weight loss, condition, avoidance of heat, humidity, and
altitude) and NSAIDs.
Dr. Cady reported that the IHS defines benign cough headache as
have a sudden, bilateral onset precipitated by coughing and
lasting about 1 minute (Cephalalgia. 1988;8(suppl 7):1-96).
In one series of 30 patients, 13 had primary cough headache and
the remaining 17 had cough headache secondary to type I Chiari
malformation (Neurology. 1996;46:1520-1524). Duration ranged
from seconds to 30 minutes in patients with primary headache and
from seconds to 2 days in those with secondary headache. Six of
six patients with primary headache responded to NSAID therapy.
Among patients with secondary headache, none responded to
analgesics or migraine medications. Seven of eight patients who
underwent suboccipital craniotomy had improvement in pain.
According to Dr. Cady, as its name suggests, sexual headache is
precipitated by sexual activity and is not associated with any
intracranial disorder. The headache has a bilateral onset and
can be prevented or minimized by stopping sexual activity before
orgasm. The headache can be associated with three types of pain:
dull ache in the head and neck that increases with sexual
excitement; explosive or sudden severe pain that coincides with
orgasm; postcoital postural headache similar to what occurs with
low cerebrospinal fluid pressure (Cephalalgia. 1988;8[suppl.
7]:1-96).
“The explosive pain is the most common type of pain associated
with sexual headache, and it also causes the most distress in
patients and should be the most concerning to physicians,” said
Dr. Cady.
He added, however, that sexual headache is rare, affecting about
1 in 360 headache patients seen in a general neurology clinic
(Med Clin N Am. 1991;75:733-747). The headache has a 4:1 male
predominance, and does not occur consistently with sexual
arousal or activity.
When patients with exertional headache present to an emergency
department, the work-up should include CT and ECG, and lumbar
puncture in the proper setting should receive strong
consideration, said Dr. Cady. Follow-up evaluation should
include MRI or MRA and a full cardiac work-up should be
considered.
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