What Is An Exertional Headache?

Introduction

Exertional headaches are headaches which occur during or right after intense physical activity. Triggers tend to include weightlifting, running and other forms of intense exercise, as well as sexual activity and sudden bursts of exertion, like coughing.¹ The prevalence of exertional headaches varies from study to study because most people who experience them do not feel the need to seek medical help. On average, about 12% to 30% of the population suffer from exertional headaches, varying with age, gender and ethnicity.² 

Types of exertional headaches

Primary exertional headache

Primary exertional headaches are caused by prolonged or sudden intense exercise and physical activity but are not associated with other intracranial pathologies. The latter includes any conditions within the cranium or the head, such as tumours, haemorrhages or strokes.3 Patients usually experience bilateral headaches, which can last between minutes to days and only occur during or just after physical exertion.³ Although primary exertional headaches can be annoying or disturbing, they are usually harmless. 

Secondary exertional headache

Secondary exertional headaches cause similar symptoms to their primary counterpart but are caused by an underlying, more serious issue. Signs of underlying conditions include a loss of consciousness, double vision, vomiting or neck rigidity during headache episodes. Secondary exertional headaches are suspected in patients who have only had one episode, in people over 40 years old and if the episode lasts over 24 hours.² In any of those cases, medical tests should be performed to detect any underlying condition.⁴ 

Potential underlying factors  include:

• malformations within the brain
• bleeding in the area between the brain and its protective membranes (subarachnoid haemorrhage)
• Brain tumours or metastases (tumours that have migrated to the brain)
• Infections 
• Issues with blood circulation in the brain (vascular diseases) or strokes
• Issues with the cerebral spinal fluid pressure

Causes and triggers

Physical exertion

Sustained vigorous exercise, like running or weightlifting, can cause exertional headaches called ‘Exercise headaches’. These usually cause a pounding, throbbing kind of headache starting at the peak of exercise and often disappearing as activity stops. Exercise headaches tend to only last a couple of minutes, but can take up to two days to fully subside. The type of exercise does not seem to factor in as long as it is strenuous enough to double the resting pulse rate for at least 10 seconds. Fitness levels also don't seem to play a role, as exercise headaches can occur in both trained and untrained athletes.² 

Short and sudden physical exertion like coughing, sneezing or laughing can also be a trigger, causing ‘Cough headaches’. In general, they are characterised by sharp, explosive bilateral pain lasting from a few seconds to several minutes. Some patients may experience a more dull, prolonged headache lasting several hours after the trigger movement.² 

Lastly, sexual activity can also trigger exertion headaches. Three different types have been associated with the former:¹

• Preorgasmic headaches: this is a tension-like headache that usually starts early on during intercourse and is characterised by a dull pain that intensifies during orgasm. Symptoms last from hours to days.
• Orgasmic (exertion) headaches: the headache is triggered just before or at the moment of orgasm and is described as intense and explosive. Symptoms can last from minutes to hours. 
• Postorgasmic: this is linked to changes in cerebral spinal fluid pressure and is associated with posture. Symptoms can last for weeks. 

Although it is not clear why these activities can all lead to headaches, the condition is thought to be related to the expansion of blood vessels during exertion to allow more blood to flow. However, this expansion causes intracranial (in the skull) pressure, eventually leading to pain.³ 

Dehydration and electrolyte imbalance

Being dehydrated, or your body not having enough water can be another cause of headaches. This is because the brain temporarily shrinks when it does not contain enough fluid, creating intracranial pressure and pain. 

During exercise, our body loses large amounts of water by sweating, which is why it is especially important to rehydrate after physical activity.⁵ In addition, sweating and dehydration cause electrolyte deficits in our bodies. Electrolyte imbalance is directly linked to dehydration and a lack of fluids in the body and can also cause headaches.⁶  

Blood Ppressure fluctuations

Physical exertion causes rapid fluctuations in blood pressure, usually increasing due to demand from both the heart and the muscles.⁷ Although this is a common occurrence, it can lead to exertion headaches if there is a lack of autoregulation, which normally re-stabilises blood pressure. In particular, unregulated increases in blood pressure, along with the aforementioned expansion of blood vessels, cause heightened intracranial pressure, leading to pain.³

Environmental factors

The environment, especially hot or humid weather and high altitudes can further increase the chance of triggering an exertion headache. Exercising in higher temperatures or humidity causes a greater expansion of the blood vessels, heightening intracranial pressure. Additionally, warmer temperatures cause more sweat and dehydration, further increasing the risk of a headache.

At higher altitudes, there is less oxygen available in the air for the blood and body to absorb. This means that more blood needs to go to the brain to supply it with enough oxygen. However, this increases intracranial blood pressure and causes expansion of the blood vessels, leading to headaches.² 

Symptoms 

Exertion headaches most commonly cause throbbing or pulsating pain in the head. This pain can be moderate to intense and may be felt across the entire head (bilaterally) or just on one side. The onset of these headaches tends to be during or just after intense physical activity and can last for 5 minutes up to 48 hours.³ 

Primary exertional headaches do not tend to cause any additional symptoms. Secondary types, however, may cause other manifestations. 

These include:

• Nausea
• Stiff neck
• Double vision
• Loss of consciousness
• Vomiting
• Headaches lasting for several days

Diagnosis

Medical history assessment

Exertional headaches are diagnosed by elimination. This means that the patient shouldn’t suffer or have suffered from another condition that may have caused their symptoms. Therefore, a doctor’s first step in the diagnosis of exertional headaches is to investigate a patient’s medical history and the symptoms they are experiencing.

Physical examination

In addition to assessing the patient’s medical history, several imaging tests can be used to rule out any potential underlying conditions. These include:

• MRI scan: used to view the brain’s structure; this can help identify any tumours or structural issues.
• CT scan: used to assess for any recent bleeding around or in the brain.
• Angiography by CTA or MRA: used to check the blood vessels leading into and out of the brain
• Spinal tap: used to take a sample of the cerebrospinal fluid from the spine.
• Blood tests may also be performed to check for underlying illnesses

If these tests do not show any underlying conditions, and the patient has experienced at least two exertional headaches characterised by the symptoms mentioned above, the healthcare provider can diagnose primary exertional headaches.³

Treatment and management

Lifestyle modifications

One option for patients suffering from primary exertional headaches is to stop doing the triggering activities. However, this is far from ideal. Instead, it may be beneficial to warm up gradually before strenuous exercise. For example, warming up adequately and slowly building up speed instead of going straight into sprints may be a good option for runners. If strenuous sexual activity is a trigger point, it is best to reduce intensity. In addition, you should:

• Reduce weights lifted during weightlifting
• Monitor and control blood pressure
• Change positions during sexual activity
• Avoid exercise at high altitudes or extreme  temperatures
• Stay hydrated, especially when exercising
• Cool down properly after exercise
• Eat a healthy, balanced diet
• Get enough rest and sleep

Medication

Common medications used to treat exertional headaches are:

• Indomethacin 
• Propranolol
• Naproxen
• Ergonovine
• Phenelzine

The dosage of these drugs will depend on the frequency and severity of the headaches. If they are occasional and predictable, the medication may only need to be taken before participating in any potentially triggering activities. If they are more frequent, however, a regular medication regimen will have to be put in place.¹

Addressing the underlying condition

If the exertional headaches are caused by an underlying issue, treating the latter should get rid of the headaches. This treatment will depend on the condition, including but not limited to chemotherapy, medication and surgery.² 

Summary

• Exertional headaches are triggered by intense physical or sexual activity.
• Symptoms include a throbbing or pulsating headache that starts during or just after exercise and persists for minutes to days.
• The cause is not completely known, but the condition is thought to be linked to increased blood pressure in the brain, leading to pain. 
• If experiencing additional symptoms like nausea and loss of consciousness, the exertional headaches may be due to an underlying cause and need urgent medical attention. 
• Primary exertional headaches are diagnosed by elimination, so any other conditions need to be ruled out as a cause. 
• Primary exertional headaches are relatively harmless and can be treated through pharmaceutical and non-pharmaceutical approaches. 

If experiencing exertional headaches, it is important to seek professional help to rule out more serious conditions and to help find the correct treatment.