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Exertional Headaches

“Pretty much every time I’m done with soccer practice I have a headache.”  Sam, a 20 year old college soccer player, had finally decided it was time to get this problem checked out.  “And usually the harder and hotter the practice the more intense the pain.  Sometimes it makes me a little sick at my stomach and it usually hangs on for several hours.”

Or there is the thirty something man whose concern overcame his feelings of awkwardness: “So, lately when I’m getting intimate with my wife, at some point, bam!, my head feels like it explodes… makes it kind of hard to stay interested if you know what I mean.”

These kind of exertional headaches are not a new medical issue.  Around 450 BC the famous ancient physician, Hippocrates, wrote, “One should be able to recognize those who have headaches from gymnastic exercises or running or walking or hunting or any other reasonable labor or from immoderate venery [sexual indulgence]”.

The first big job of sorting through these kind of headaches is dividing them between those that are a painful, but not dangerous, nuisance, and those that have some other serious cause behind them such as a brain tumor, aneurysm, or other significant abnormality.  The former are called primary exertional headaches (PEH) and about 90% of exertional headaches fall into this category.

To make this distinction between PEH and those that are called secondary exertional headaches (SEH) where there is an underlying abnormality, some kind of brain imaging, such as an MRI, is usually needed.  PEH is more likely to occur in hot weather or at high altitude, or if alcohol or caffeine have been consumed prior to or during exercise.  The good news is that PEH tends to stop occurring after three to six months.  Also, sometimes a change in exercise regimen or treatment can help prevent PEH.

There is yet another type of exertional headache – migraine triggered by exertion.  These occur in individuals who have migraines and find that there typical migraines are sometimes triggered by exercise or sex.

Added together, how common are these exercise-related headaches.  Estimates vary from a few percent to a study that indicated that 35% of a large test group experienced exercise-induced headaches at some time. Of course if someone has had previous concussions, the incidence of exertional headaches is even higher.  In one study 96% of post-concussion football players had exertional headaches.

What does a typical exertional headache feel like?  They are typically felt on both sides of the head, are throbbing or pulsatile in quality, and can last anywhere from five minutes to 48 hours after arising during or after physical exercise.  Triggers can include exercise, cough, sneeze, straining at stool, or having sex.

In PEH, preventive meds such as the anti-inflammitants naproxen and indomethacin, or beta blockers such as propranolol can sometimes greatly reduce the frequency and intensity of PEH’s.

So the bottom line is, if you get significant headaches when you exercise, get it checked out.  Up to one in ten may turn out to have a significant underlying cause.  And even the others may be worth treating or preventing to keep you from needlessly limiting your exercise and marital venery.

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