Dr. Chan of King's College London has no relevant financial relationships to disclose.)
Dr. Goadsby of King’s College London and the University of California, San Francisco, received fees from Aeon Biopharma, Alder Biopharmaceuticals, Allergan, Autonomic Technologies Inc, Biohaven Pharmaceuticals Inc, Clexio, Electrocore LLC, eNeura, Epalex, GlaxoSmithKline, Impel Neuropharma, Lundbeck, MundiPharma, Novartis, Pfizer, Sanofi, Santara Therapeutics, Teva Pharmaceuticals, Trigemina Inc, and WL Gore; consulting grants and fees from Amgen and Eli-Lilly and Company; and a grant from Celgene.)
Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, received honorariums from Abbie, Curelator, Ipsen Therapeutics, Lundbeck Biopharmaceuticals, Supernus Pharmaceuticals, and Theranica for consulting. He is also the principal investigator for clinical trials conducted by Amgen, ElectroCore Medical, and Teva.)
Primary exercise headache is a rare headache syndrome where headache can be induced during or after physical exertion. Intracranial pathology can present with exercise-induced headaches and therefore it is imperative to investigate for secondary causes. Other Valsalva-induced headache syndromes, primary cough headache and primary headache associated with sexual activity, are discussed in dedicated MedLink Neurology articles.
• Primary exercise headache is a diagnosis of exclusion. Headache induced by exertion is a red flag and imaging is necessary to rule out secondary causes.
• Phenotypically, the headache begins within 30 minutes of cessation of exertion, typically lasts up to 4 hours, and can be associated with migrainous features.
• Prevention of headache attacks can be through modification of exercise. Where this is not possible or successful prophylactic indomethacin can be utilized.
• Patients typically experience spontaneous resolution.
Historical note and terminology
Headache associated with exercise or exertion has been noted as early as classical Greece, when Hippocrates wrote “one should be able to recognize those who have headaches from gymnastic exercises, or running, or walking or hunting, or any other unseasonable labour, or from immoderate venery…” (Adams 1848).
The first description in modern medicine was in 1932 by Tinel who presented 4 patients with intermittent, paroxysmal headaches following exertion and surmised the cause was distention of the intracranial veins due to increased intrathoracic pressure (Tinel 1932). Symonds's observations differentiated this further and described headaches induced by Valsalva-like maneuvers and not exertion (Symonds 1956), now classified as primary cough headache (Headache Classification Committee of the International Headache Society 2018).
He later noted several profound cases of “effort migraine” during the Olympic Games in Mexico City (Jokl and Jokl 1977). He described high altitude heat, humidity, and perhaps lack of training as predisposing factors. These headaches 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. These descriptions are more in keeping with migraine triggered by exertion.
The first large published series on exertion-induced headache or head pain related to exertion came from the Mayo Clinic (Rooke 1968). The cohort included 103 patients with headache precipitated by running, bending over, coughing, sneezing, straining, or by heavy lifting. Of their cohort, 90% were diagnosed with “benign exertional headache unassociated with intracranial lesions”; however, the phenotype was not differentiated by either precipitation with sudden Valsalva maneuvers or sustained exertion/exercise.
Primary exercise headache was initially termed “benign exertional headache” in the first edition of the International Classification of Headache Disorders (Headache Classification Committee of the International Headache Society 1988). It was subsequently renamed “primary exertional headache” in the second edition (Headache Classification Committee of the International Headache Society 2004) and is now classified as “primary exercise headache” in the third edition (Headache Classification Committee of the International Headache Society 2018).
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