15 Oct Does your head hurt after exercise?
By Dr. Matt Fontaine Does your head ache after workouts? Sports related headache Headache following exertion has been documented to have been described by Hippocrates1. Mainstream medicine often classifies headaches as either migraine or tension type headache. But the evidence based research does bot necessarily support this simplistic categorization. Simply said, many of the headaches people may deem as “normal” actually represent cervicogenic/tension type headache. Meaning, the headache is caused by tightness in the muscles at the base of the skull and neck and upper back and shoulders, resulting in compression of the neck joints and discs. Migraine can be thought of as an episodic brain issue, anyone at one time or another can experience a migraine headache. It is the ongoing occurrence that sets the migraine patient apart from the occasional headache. Statistics show that 3 % of children can experience migraine, 7-11 % of adolescents. During puberty, migraine occurrence increases in women and by adulthood migraine in women nears 18% while only 6 % in men. Incidence is greatest between the ages of 20-40 and decreases dramatically after age 60. The International Headache Society has set forth the following criteria for migraine: 1.) at least five attacks lasting 4-72 hours (untreated or unsuccessfully treated); 2) two of the following characteristics: unilateral, throbbing, moderate to severe intensity, aggravated by routine activity and 3.) one or more of the following: nausea, vomiting, phonophobia, photophobia2. Understanding what causes migraine headaches. There are two theories accepted: 1.) neurovascular inflammation and 2.) Serotonin dysregulation. Other research shows the brain is hyper-excitable between attacks. The cause of this may be magnesium deficiency or mitochondrial dysfunction. Magnesium deficiency is prevalent in most of us, especially athletes. Athletes’ daily requirements of magnesium are much higher due to the rigors of exercise on muscle tissue. As many as 30 % of migraine sufferers have been found to have low levels of intracerebral magnesium.3 Sports Related Headache These headache types can be broken down into four categories4:
- Exertional Headache
- Prolonged exertion as trigger for migraine
- Trauma triggered migraine
- Posttraumatic headache.
Exertional headache is described as bilateral, throbbing, often times moderate to severe pain behind the eyes. As this type is the most common we see in recreational athletes, we will focus in greater detail on this headache type. These typically last 5-24 hours following heavy lifting or strenuous exercise. The mechanism for these headaches is an increase in tightening of the posterior musculature of the neck and the muscles on the sides of the neck (sternocleidomastoid). As these muscles over-tighten, they compress the cervical vertebrae, joints and discs. More importantly is they can compress the occipital nerves, which sit at the base of the skull within the suboccipital triangle. These triangles sit one on either side of the back of the head and are formed by four small muscles that form a triangle at the base of the skull. These muscles attach to the first two cervical vertebrae and the base of the skull, and they are responsible for most of the rotation of your head. With prolonged periods of poor posture (think computer guy), these muscles become shortened. Then during a heavy lifting session they can become even tighter, generating a headache that can range from nagging to seriously painfully nauseating and debilitating. Figure 1. Shows the suboccipital muscles which sit at the base of the skull and are responsible for more than half of the rotation of your head and neck during turning. These muscles sit deep to the semispinalis and splenius muscles and are often tight and glued down. These muscles can squeeze the occipital nerve, resulting in frontal eye pain and headache. These muscles often get hypertonic(tight) following strenuous exercise, including running and strength training. Patients over 50 who experience exertional headache, should have a cardiac evaluation to rule out myocardial ischemia (low oxygen flow). Myocardial ischemia is a treatable form of exertional headache. Effort migraine or prolonged exertional migraine can be seen in some who are predisposed to migraine due to exercise. Additional triggers like dehydration, low blood sugar, excess heat, altitude may play a role. Trauma Triggered Migraine is typically seen in children, adolescents and young adults after a mild blow to the head. Symptoms include temporary vision changes, change in level of consciousness, severe headache, nausea and vomiting. Symptoms typically onset 1-10 minutes following the blow and usually resolve in 24 hours. These posttraumatic attacks may be mistaken for cerebral concussion, contusions, or acute epidural or subdural hematoma.5-7 Posttraumatic Headache implies onset of headache after injury. Typical onset is within 14 days after injury. As with trauma triggered migraine, these headaches may need medical evaluation, depending on persistence of symptoms. Most high school, collegiate and pro level athletes undergo a preseason mini mental evaluation and baseline SCAT3 (Sport Concussion Assessment Tool 3rd edition). These baselines can be used by athletic trainers and team physicians to determine return to play status and other treatment options, including monitoring the athlete. What to do: Treatments can be divided into nonpharmacological and pharmacological. Magnesium supplements 200-400 mg per day of a good magnesium supplement that includes a combination of (magnesium aspartate, magnesium glycinate, and magnesium gluconate). Active Release Techniques Manual Release treatment in combination with manipulation is highly effective and safe in reducing the soft tissue and joint dysfunction that contributes to exertional headache. Corrective exercises to rehabilitate posture and strengthen deep flexor muscles of the neck are also very important. On the medical side, if headaches are at least twice per week and not easily aborted, some medication can play a short term role in modulating headache symptoms. Many patients often do extremely well combining conservative manual treatment/manipulation with short term medication use. Some types of medication prescribed: Calcium channel blockers: typically used to address pain generators by decreasing irritability of tissues. Nicardipine and Verapamil are commonly used. Selective Serotonin Reuptake Inhibitors Indomethacin: acts as anti-inflammatory and also antagonist for nitric oxide to address vasodilation. Post Workout Exertional Headache can affect many athletes. Conservative treatment is highly effective and should be first in line for treatment options. The key is to seek a practitioner who is skilled at soft tissue treatment, manipulation and functional rehabilitative exercises. Combing all three of these components leads to the best outcomes. References
- Braun A, Klawans H. Headaches associated with exercise and sexual activity. In: Rose FC, ed. Handbook of Clinical Neurology. Amsterdam: Elsevier; 1986:373-382
- Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and face pain. Cephalalgia 1988; 8(suppl 7):1-96
- Welch K. Synthesis of mechanisms. 49th Annual Meeting, American Academy of Neurology, April 12-19, 1997
- Williams S, Nukada H. Sports and exercise headache: Part 2. Diagnosis and classification. Br J Sports Med 1994;28:96-100
- Haas D, Pineda G, Lourie H. Juvenile head trauma syndromes and their relationship to migraine. Arch Neurol 1975;32:727-730
- Haas D, Lourie H. Trauma-triggered migraine: an explanation for common neurological attacks after mild head injury. J Neurosurg 1988;68:181-188
- Matthews W. Footballer’s migraine. Br Med J 1972;2:326-327
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