Activity-related headache

Julio Pascual MD (Dr. Pascual of University Hospital Marqués de Valdecilla and IDIVAL in Santander, Spain, received honorariums for serving on the advisory boards of Allergan and Amgen-Novartis.)
Stephen D Silberstein MD, editor. (

Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, receives honorariums from Allergan, Avanir Pharmaceuticals, Curelator, Depomed, Dr. Reddy's Laboratories, eNeura,  INSYS Therapeutics, Lilly USA, Supernus Pharmacerticals,  Thernica and Trigemina for consulting. He is also the  principal investigator for a clinical trials conducted by Alder Biopharmaceuticals, Amgen, electroCore Medical, Lily USA and Teva.

Originally released September 26, 1996; last updated October 8, 2017; expires October 8, 2020

This article includes discussion of activity-related headache, exertional headache, and benign exertional headache. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.


Activity-related headache can be provoked by Valsalva maneuvers (“cough headache”), prolonged exercise (“exercise headache”), sexual excitation (“sexual headache”), and ischemic cardiomyopathy (“cardiac cephalgia”). These entities are a challenging diagnostic problem as they can be primary or secondary, and their etiologies differ depending on the headache type. In this article, the author updates this topic, including the revised diagnostic criteria that emphasize that cough headache is different from both exertional and orgasmic headache, which share many common points, and that cardiac cephalgia is not uncommon at rest. New etiologies for secondary exertional headaches, such as reversible vasoconstriction of vertebral artery aneurysms, are added.

Historical note and terminology

In 1932, Tinel presented several patients with intermittent, paroxysmal headaches following exertion and maneuvers that increased the intrathoracic pressure (Tinel 1932). Later, Symonds called the disorder "cough headache" and demonstrated that it may be a benign syndrome without demonstrable cause (Symonds 1956). Jokl described “migraine” that occurred after exercise (Jokl 1965). The first large published series on exertional headache or head pain related to exertion came from the Mayo Clinic (Rooke 1968).

Jokl and Jokl noted several profound cases of effort migraine during the Olympic Games in Mexico City (Dalessio 1974; Jokl and Jokl 1977). The high altitude was an obvious predisposing factor, as were heat, humidity, and perhaps lack of training. Migraine after effort tended to occur with prolonged running rather than sprints. These highly conditioned athletes developed scotomata, unilateral retro-orbital pain, nausea and vomiting, and, in some cases, a striking prostration.

A number of authors have included cough headache in the broader context of exertional headache, but cough headache has clinical features that differentiate it from exertional headache and presumably has a different pathogenesis.

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