Quote[/b] ]Exertional Headache
Benign exertional headache has been recognized as a separate entity for more than 60 years. In 1932, Tinel (7) first described severe but transient headaches following exercise. Since then, these headaches have been associated with exercises such as weightlifting (8) and wrestling (9).
Recent studies (8-10) have delineated a clear-cut exertional headache syndrome: Straining or a Valsalva-type maneuver precipitates the acute onset of severe throbbing pain, usually occipital, for a few seconds to a few minutes. The headache then settles to a dull ache lasting 4 to 6 hours. In subsequent weeks to months, the headache recurs with exertion. The patient has no history of migraine and a normal neurologic exam.
In the largest series to date, Rooke (11) followed 103 patients with benign exertional headaches and found that approximately 10% had an organic cause for the pain, usually a skull-base anomaly. Clearly, the major differential diagnosis--subarachnoid hemorrhage--needs to be excluded by appropriate investigation.
Exertional headaches are thought to be vascular, but this is unproven. According to one theory, exertional headache occurs because exertion increases cerebral arterial pressure, causing the pain-sensitive venous sinuses at the base of the brain to dilate. Studies of weight lifters (12) demonstrate that, with maximal lifts, systolic blood pressure may reach levels above 400 mm Hg and diastolic pressures above 300 mm Hg. The throbbing, migrainous nature of these headaches, together with the finding (13) that intravenous dihydroergotamine mesylate can relieve them, supports the supposition that these headaches have a vascular basis.
A related type of vascular headache caused by sexual activity is termed benign sex headache or orgasmic cephalgia (13). Angiographic studies (14) of both benign exertional and benign sex headaches have demonstrated arterial spasm, further implicating the vascular tree as the basis of these conditions. However, despite their vascular nature, no convincing association with migraine is demonstrable.
Treatment strategies include NSAIDs such as indomethacin at a dose of 25 mg three times per day (15). In practice, the headaches tend to recur over weeks to months when the patient performs the provoking activity and then slowly resolve without treatment, although some cases may be lifelong. In the recovery period, a graduated symptom-limited weightlifting program is appropriate.
7.Tinel J: La céphalée à l'effort, syndrome de distension douloureuse des veines intracraniennces. Médecine 1932;13(Feb):113-118
8.Powell B: Weight lifter's cephalgia. Ann Emerg Med 1982;11(8):449-451
9.Perry WJ: Exertional headache. Phys Sportsmed 1985;13(10):95-99
10.Diamond S, Medina JL: Prolonged benign exertional headache, in Critchley M (ed): Headache: Physiopathological and Clinical Concepts. New York City, Raven Press, 1982, pp 145-149
11.Rooke ED: Benign exertional headache. Med Clin North Am 1968;52(4):801-808
12.MacDougall JD, Tuxen D, Sale DG, et al: Arterial blood pressure response to heavy resistance exercise. J Appl Physiol 1985;58(3):785-790
13.Hazelrigg RL. IV DHE-45 relieves exertional cephalgia. Headache 1986;26(1):52
14.Silbert PL, Hankey GJ, Prentice DA, et al: Angiographically demonstrated arterial spasm in a case of benign sexual headache and benign exertional headache. Aust N Z J Med 1989;19(5):466-468
15.Diamond S, Medina JL: Prolonged benign exertional headache: clinical characteristics and response to indomethacin. Adv Neurol 1982;33:145-149
