Primary Exertion Headaches: Symptoms, Causes, Prevention, Treatment, Ayurveda Understanding

Article by Dr Manasa S, B.A.M.S

Overview

Exertion headaches can occur during or after strenuous physical activity which particularly involves tensing the abdominal muscles or increasing the pressure in the chest.

Activities associated with exercise headaches include running, rowing, tennis, swimming, weightlifting or even sexual intercourse. These headaches are also known by the name ‘Exercise headache’.

This type of headache most often begins after strenuous activity and lasts for a few seconds to minutes. When there is continuous exertion then headache might last for longer duration. In most cases there is no underlying disorder and these types of headaches come and stay for a few minutes and then pain goes off. But few cases of exertional headache need proper evaluation when they are not going easily and there are frequent episodes of headache followed by strenuous activities and if they are associated with additional symptoms and when headaches are interfering in the day today activities.

Classification of exertion headaches

  1.  Primary Exertion Headaches:

   – Usually harmless and not linked to underlying problems.

   – Can often be prevented with medication.

2. Secondary Exertion Headaches:

   – Caused by underlying, often serious issues within or outside the brain like tumours, sinus infection, subarachnoid haemorrhage, coronary artery disease, structural abnormalities of head, neck, or spine and obstruction to flow of cerebrospinal fluid.

   – May require emergency medical attention.

Symptoms

Patients with PEH typically experience bilateral pulsatile or throbbing head pain during episodes that can last anywhere from 5 minutes to 48 hours. Notably, these headaches are consistently triggered by strenuous exercise. According to the International Classification of Headache Disorders 3rd edition, PEH is defined as having at least two headache episodes lasting less than 48 hours, precipitated by or occurring during strenuous exercise. Nausea and vomiting are not commonly associated with PEH based on available information.

Few symptoms are as under:

1. Primary Exertion Headaches

• Described as a throbbing or pulsating sensation.
• Occur during or after strenuous exercise.
• Typically affects both sides of the head.

2. Secondary Exercise Headaches:

• May exhibit the same symptoms as primary exercise headaches.
• Additional symptoms may include vomiting, loss of consciousness, double vision, and neck stiffness.

3. Duration:

• Primary exertion headaches last between 5 minutes and 48 hours.
• Secondary exertion headaches typically last at least a day and can persist for several days.

Causes

1. Primary Exertion Headaches:

• Exact cause is unknown.
• One theory suggests that strenuous exercise dilates blood vessels inside the skull. This expansion and increased blood pressure in the skull causes pain.

2. Secondary Exertion Headaches:

Caused by underlying issues such as bleeding in the brain, irregularities in blood vessels, tumours, obstruction of cerebrospinal fluid flow, sinus infection, or structural irregularities in the head, neck, or spine.

Brief understanding of pathophysiology of primary exertion headache

In simple terms, exertional headache (PEH) is believed to be linked to problems in the blood vessels in the brain. Specifically, when the valves in the neck veins don’t work well during activities like straining, it can increase pressure in the chest and reduce blood drainage from the brain. This can result in a temporary increase in blood flow to the head, leading to headaches. A study found that 70% of exertional headache patients showed this abnormal blood flow. Additionally, issues with the normal regulation of blood vessels in the brain have been discussed in exertional headaches and other types of headaches. When the ability to maintain steady blood flow in the face of changing pressures is compromised, it may contribute to exertional headaches. Regular physical exertion causes rapid changes in blood pressure, and in a system without proper regulation, this can lead to increased pressure in the head and, consequently, pain.

Risk Factors

Though the exact cause for the exertion headache is not clearly understood, few risk factors have been identified and they are as below:

• All age groups are equally susceptible to exertional headache but people over the age of 40 years are at higher risk.
• Exercise in hot weather.
• Exercise at high altitudes.
• Have a personal or family history of migraine.

Diagnosis

• Detailed history taking followed by physical examination
• CT scan to check if there is a recent bleeding in or around the brain
• MRI scan to understand the structural abnormalities, if any
• Magnetic resonance angiography and CT angiography to visualise the blood vessels leading to brain
• Spinal tap test to measure the flow of cerebrospinal fluid.

Prevention  

• Exertion headaches are more common in hot and humid weather or at high altitudes. If prone to exercise headaches, consider avoiding exercise in these conditions.
• Avoid working out in high altitudes, if someone is not used to it.
• Some people may prevent headaches by avoiding specific activities.
• Warm-up before strenuous exercise can help prevent exercise headaches.
• Maintain enough hydration
• Get enough rest before and after strenuous exercise
• Plan the exercise schedule intelligently by mixing both low intensity and high intensity exercises
• Proper warm up and cool down techniques should be inculcated if strenuous activities are the cause for headaches.
• Wearing sunglasses while being in the hot weather or sun
• Choose for moisture-wicking clothes when in hot weather
• Consume a healthy, well-balanced food
• Certain research suggests that taking supplements like magnesium, vitaminB12, Boswellia can help to prevent exertion headaches.

When to connect with the healthcare provider?

• If the headache is severe and the onset is sudden
• Headache lasting for more than two days
• Experiencing sleepiness or confusion
• Faint or syncope

Management and treatment of primary exertion headache.

As primary exertion headaches are mild in nature and they are not a serious condition, they can be treated in the same lines as regular headaches. Preventive measures in this type of headache play an important role.

Few medications include –

–         Nonsteroidal anti-inflammatory drugs like indomethacin can be used for short duration
–         Over-the-counter painkillers like naproxen can be used for small time period
–         Betablockers, like nadolol and propranolol can be used for a longer time or in whom NSAIDS are contraindicated.

Prognosis

Most exertion headaches, especially the primary exertion headaches resolve with minimal intervention. Only secondary exertion headaches need proper understanding to outline the treatment strategies.

Ayurveda Understanding of Exertion Headache

There is no exact condition explained in Ayurveda which can be perfectly compared with exertion headache. Understanding the disease from Ayurveda perspective, we can infer that exertion increases vata and this vata causes headache. So, by default, exertion headache falls under the category of vataja shiroroga or vataja shirashula.

The description of exertion headache also brings pittaja and raktaja shiroroga and ardhavabhedaka into the discussion alongside it. Management of exertion headache through Ayurveda is based on principles of treating the mentioned conditions.

Related Reading – ‘Exertion Headache – Ayurveda Understanding’