Migraine in the Athlete

Judy C. Lane, MD, The Head Pain Center, Englewood, Colorado.

Semin Neurol. 2000;20(2) 

In This Article

Sports-Related Headache

In my practice, which includes both professional and amateur athletes with headaches, I think about sports headache similarly to the framework proposed by Williams and Nukada 8 ( Table 1. ). The four categories of sports headaches as described by Williams and Nukada are (1) effort-exertional headache, (2) effort migraine (in this article referred to as prolonged exertion as a trigger for migraine), (3) trauma-triggered migraine, and (4) posttraumatic headache.8 In my practice, I have modified this framework because I think of any bad episodic headache as migraine. Keep in mind that headache sufferers often experience headaches in one or more of these categories.

Exertion or Effort Headache

Exertion or effort headache is a benign headache precipitated by any form of exercise. The headache typically occurs de novo in an otherwise healthy person who has not been prone to headaches.9 According to IHS criteria, the headache is bilateral, throbbing at onset, and may develop migrainous features in those predisposed to migraine. Duration is 5 minutes to 24 hours. The headache may be prevented by avoiding excessive exertion, particularly in hot weather.5

Evaluation of exertion headache includes a thorough patient history. The physician should inquire: What effort or activity triggers headache? Does the headache increase in intensity along with the effort? How quickly does the headache peak? How long does the headache last after effort stops? Is the headache associated with other symptoms? Are migraine features present? Is there anything unusual or concerning in presentation? Was there recent trauma or illness? Is there a history of altitudinal headache? Does coughing, sneezing, Valsalva, or sex trigger headache?

Effort migraine has been reported in various settings. Several cases were reported during the 1977 Olympic Games in Mexico City. Young, well-conditioned athletes developed scotoma, severe retroorbital pain, nausea, and vomiting. The rather unusually high incidence of this condition during the Mexico City games suggested that high altitude may have been a contributing factor.9

In new onset headache after the age of 50, cardiac evaluation is indicated. A particularly important cause of exertion headache has been reviewed in the older athlete. Lipton and associates 10 suggested the term "cardiac cephalgia" in patients who presented with exertional headache as the most prominent manifestation of myocardial ischemia. In response to exertion, two men aged 57 and 67 quickly developed severe bilateral head pain. One patient reported nausea. Neither had a known history of heart disease. Neither man complained of chest discomfort, diaphoresis, or palpitations. During treadmill testing, head pain recurred and cardiac ischemia was seen. Myocardial ischemia is a treatable cause of exertional headache. Accurate diagnosis is critical to prevent myocardial infarction as well as to offer headache control.

Basoglu et al 11 reported a case of a 15-year-old boy who suffered exclusively with exercise-induced headache and had migraine-like accompanying symptoms. Single photon emission computer tomography (SPECT) was performed during a typical attack. Perfusion- related pathology was demonstrated. Asymmetrical decreased regional cerebral blood flow was seen in both frontal cortices. The SPECT scan was thought to support a pathogenetic relationship to migraine.11

In patients with effort headache, the physical examination, including a neurologic examination, is typically normal. Examination should include blood pressure measurement and auscultation of the head and neck to detect bruits. If one suspects an intracranial mass lesion (tumor, aneurysm, arteriovenous malformation, Arnold-Chiari malformation) then magnetic resonance imaging (MRI) or computed tomographic (CT) scanning is indicated. MRI can be done in conjunction with a Valsalva maneuver to assess the presence of tonsillar herniation. If a subarachnoid hemorrhage is suspected, further studies such as MR angiography and arteriography or a lumbar puncture (LP) to rule out intracranial blood may be needed. Prior to LP, imaging is necessary to rule out increased intracranial pressure. For new onset headache after age 50, cardiac evaluation is indicated.

The exertional activity should be discontinued until the diagnosis is established. Often pharmacological therapy helps these patients. If the attacks occur predictably, treatment can be administered just before exertion. For attacks that are frequent and not always predictable, preventive therapy may be the best choice.

Indomethacin is the "gold standard" for exertional headache. For infrequent and predictable headache it can be taken 1 to 2 hours before exertion. If headaches are more frequent, it can be taken daily at 25 to 50 mg three tims a day (t.i.d.). Because of the probable relation to migraine, migraine preventive medications are often beneficial.

Prolonged Exertion As A Trigger For Migraine

Athletes with predisposition to migraine may have prolonged exertion as one trigger for a typical migraine. The headache does not typically resolve when the activity is discontinued. The headache may occur minutes or hours into the activity or after cessation of activity.

Effort migraine was seen in 9% of 128 subjects reported by Williams and Nukada.8 In the study population, such headaches often began in childhood or adolescence with average age at onset of 15. Aura was noticed by all, nausea by the majority, and vomiting and neck stiffness were frequent. The headache was generally throbbing, moderate to severe, and lasted for hours. Spontaneous migraine unrelated to sport or exercise was experienced in 55% of subjects, with a positive family history in 64%. The authors suggested that low oxygen tension may trigger effort migraine by an as yet unknown mechanism.

For a headache to occur with prolonged exertion, additional triggers may be required. Such triggers include heat, altitude, bright light, dehydration, and low blood sugar. Swain and Kaplan 12 reported headache development after use of certain types of athletic equipment. Poorly fitting mouth guards, tight helmets, and goggles were noted as potential triggers for the athlete with migraine.

"Goggle" migraine has been described by neurologist Alan Pestronk.13 He developed a migraine headache beginning 1 to 2 hours after exercise and occurring only on days when he swam. His father, a retailer of sporting goods, noted anecdotally that his customers frequently complained of headaches associated with the use of ill-fitting swim goggles. When Dr. Pestronk changed to a goggle not requiring a tight head strap, he had no further migraine headaches.

Another interesting case report in the literature is of a 48-year-old woman who consistently developed migraine after completing aerobic exercise class. Switching from a "high impact" to a "low impact" exercise regimen was not beneficial. A change in her estrogen replacement therapy was observed to be the responsible second trigger. She had changed from a pill form to a patch prior to the development of headache. The patch, along with exercise-associated vasodilatation, increased absorption of estrogen. The estrogen "bolus" then precipitated a vascular headache. Removal of the patch during exercise solved the problem.14

The evaluation of the athlete with exertion as one trigger for migraine is the same as that of any patient presenting with headache. Special emphasis on triggers related to the athletic event should be reviewed. These might include use of equipment, environmental factors (e.g., sunlight or altitude), or diet.

Some athletes with prolonged exertion as a trigger for migraine respond to pretreatment with indomethacin (Indocin). Other anti-inflammatory medications could be tried as well. These and other treatments are discussed in the following.

Trauma-Triggered Migraine

Trauma-triggered migraine is typically seen in children, adolescents, and young adults. It represents a complex temporary disturbance of brain function precipitated by a mild blow to the head. The attack may begin with visual disturbance such as temporary blindness, change in level of consciousness, or hemiparesis or brain stem symptoms. A severe headache, nausea, and vomiting follow. Symptoms begin 1 to 10 minutes after a blow to the head but are not triggered by blows to the rest of the body. The attack usually resolves within a few hours to 24 hours. Rarely, neurologic deficits do not totally clear. These posttraumatic attacks may be mistaken for cerebral concussions, contusions, or acute epidural or subdural hematoma.15-17

Trauma-triggered migraines have been reported with soccer, football, volleyball, and wrestling. These headaches are more typical in boys and young men because of their involvement in contact sports. Except that the trigger is trauma, the presentation is similar to that of other migraine attacks. The incidence of spontaneous migraine is much higher in children with trauma-triggered migraine. A positive family history of migraine is present in 77% of children with this variety of headache.

In 1980 Bennett et al 18 of the University of Nebraska reviewed three members of a university football team, 18 to 21 years old, who were evaluated because of migraine symptoms precipitated by head trauma. The head trauma was usually minor and not associated with amnesia. Visual, motor, sensory, or confusional signs and symptoms began after a short symptom-free interval. Symptoms lasted for 15 to 30 minutes and were followed by a headache frequently accompanied by nausea and vomiting. In 9 of 11 cases the attacks reoccurred with subsequent head trauma.

The differential diagnosis includes concussion, focal brain injury, seizure, and stroke. By the time the patient presents to the neurologist, an imaging study has often been done. If the neurologic evaluation is nonfocal and the spell appears to be consistent with migraine, imaging studies may not be necessary. Matthews 17 noted that because of the widespread and erroneous belief that complicated migraine is associated with vascular anomalies, patients often fear that they have a more serious condition. He believed that if there were no physical abnormalities or sequelae, elaborate investigations may not be required. Rather, for children participating in routine physical activities, observation may be sufficient.

In the athlete who plays football, an additional concern is the possibility of traumatic intracranial hemorrhage. According to Bennett et al,18 participation should be continued only after a thorough neurological evaluation. The athlete should be apprised of his condition and any abnormalities found on examination. The neurologist should warn the patient to report to the team physician or trainer if neurological symptoms recur.

Posttraumatic Headache

Posttraumatic headache implies a new onset headache after injury. To be directly attributable to the trauma, no precursors for migraine were present before the onset of the headache. The assumption is that the trauma caused the headache by altering brain function or structure.19 Trauma can also provoke the first episode of migraine in a predisposed individual or exacerbate a pre-existing headache condition. Onset usually occurs within 14 days after head trauma. Solomon 19 gives the following analogy for trauma triggering the first attack of migraine in the predisposed individual: "Trauma," shaking a branch of the tree, will cause the fruit to fall, but even without "trauma" the ripe fruit will soon fall.

I have seen several patients who developed a chronic headache after a seemingly minor blow to the head with a basketball or volleyball. Such headaches may present as migraine, tension-type headache, or daily headache with varying degrees of migraine symptomatology. Posttraumatic headache is more likely to occur in a predisposed individual than in an individual with no history of headache and no family history of headache.

Williams and Nukada 8 reviewed 29 subjects with posttraumatic headache as a result of head trauma in a contact sport. The headaches were not classified as migraine. The trauma was usually minor. Associated symptoms included stiff neck, confusion, and loss of concentration. Some subjects were unable to continue the sport or exercise because of severe headache. A number of the subjects appeared to have susceptible migrainous features such as a family history of migraine or prior spontaneous migraine. The posttraumatic headache was often associated with concussion.

If the examination is normal, it is unlikely that an imaging study will add further information. The decision to order further studies is at the discretion of the evaluating physician. Swain and Kaplan 12 note that medical-legal concerns often necessitate that laboratory studies be done although studies are unlikely to be helpful.


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