Headache in the Athlete

The exact cause of many headaches is a source of much debate and likely differs for each specific type of headache. Physiologic changes in the head and brain that consist of, but are not limited to, changes in neurotransmitter regulation, vascular dilation and constriction, and cranial nerve irritation that cause activation of pain signals are all contributors to the development of headache. Cyclical hormonal changes and genetic predisposition are also thought to play an important role.

Tension-type headache (TTH), migraine, and cluster headaches combine to make up >90% of headaches experienced by the general population.

Adults mostly experience TTHs, whereas children are more likely to have migraine headaches.

• Among children aged 3–18 years who visit pediatric neurologic clinics, vascular/migrainous headaches account for 52%, chronic headaches/TTHs for 21%, and unclassified headaches for 19%. Remainders are mixed tension-migraine, psychogenic, or posttraumatic.

Of headache-caused emergency department visits:

• Migraine and TTHs account for 25%–55% of visits.

• Headache associated with systemic illness accounts for 33%–39% of visits.

• Headache caused by a serious neurologic condition (subarachnoid hemorrhage, intracranial mass, meningitis, or hemorrhage) accounts for 1%–16% of visits.

In 1988, the International Headache Society (IHS) created its first classification of headache disorders. This International Classification of Headache Disorders (ICHD) has subsequently been updated and revised twice, with finalization of the third version (ICHD-3) occurring in 2018.

Headache has many causes. The IHS classification gives a physician a logical approach to make a rapid and accurate differential diagnosis.

Headache disorders are classified as primary, secondary, or those caused by cranial neuralgias.

• Primary headaches are those that have no underlying cause; there are three main types: migraine headache, TTH, and cluster headache (trigeminal autonomic cephalalgias).

• Secondary headaches are those that may be attributed to certain underlying pathologic conditions (i.e., infectious, neoplastic, vascular, psychiatric, traumatic, drug-induced, or homeostatic changes).

• Cranial neuralgia headaches are those that are initiated by compression, distortion, or irritation of specific cranial nerves and subsequently cause pain in the area that those nerves innervate.

The athletic population suffers from the same headache disorders as the general population but may also have a predisposition to suffer from other headache disorders and subtypes because of the effects of exercise and because of participation in their specific sports.

• Sports-/exercise-related primary headaches are exercise-/effort-induced migraine and primary exertional headaches.

• Sports-/exercise-related secondary headaches are acute and chronic posttraumatic headache (PTH), cervicogenic headache, high-altitude headache, and diving headache.

• Sports-/exercise-related cranial neuralgia headaches are external compression headache and cold-stimulus headache.

When was the first onset of headache?

What is the frequency?

Where is the location, and is there any radiation of pain?

What is the character of the pain (dull, throbbing, sharp)?

What is the intensity of the pain?

Are there any associated symptoms?

• Nausea/vomiting

• Photophobia/phonophobia

• Confusion

• Blurry vision

• Gait disturbances

Were any medications taken?

Are there any alleviating or exacerbating factors?

Is there a prior history of headache?

Is there a family history of headache?

Has there been a change in the headache characteristics (if prior history is positive)?

Is there a history of other medical issues?

What medications is the athlete taking?

Assess for level of consciousness, orientation, alertness, mini-mental status, and overall affect.

Check vital signs to rule out hypertension.

Evaluate head, eyes, ears, nose, and throat to assess for papilledema. Check for central nervous system abnormalities, including cranial nerve testing, ptosis, pupil reactivity, and head trauma.

Conduct musculoskeletal evaluation to assess for nuchal rigidity, temporomandibular joint problems, cervical spine range of motion, areas of scalp tenderness, and neck tenderness.

Conduct neurologic examination to assess for motor, sensory, and reflex response; also include evaluation of gait.

Check for evidence of systemic illness (assess abnormalities in the cardiovascular, respiratory, and gastrointestinal [GI] systems).

Laboratory evaluation: To rule out metabolic issues. Laboratory examinations that may aid in diagnosis are erythrocyte sedimentation rate, complete blood count, liver function tests, thyroid function tests, antinuclear antibodies, antiphospholipid antibodies, and drug screening. Appropriate tests must be conducted as indicated by the history and physical examination.

Imaging tests: Possibilities include cervical spine films, computed tomography (CT) (with or without contrast), magnetic resonance imaging (MRI), electroencephalogram (EEG), and magnetic resonance (MR) angiography. Selection of tests should be individualized.

• Cervical spine radiography (flexion/extension views) in patients with trauma/neck pain, possible fracture, and instability.

• CT scan with contrast for patients with new-onset exertional headache.

• Some experts do not advocate CT unless neurologic examination is abnormal.

• May not be helpful for suspected posterior fossa lesions

• CT better for acute bleeding and bony fractures; detects surgical lesions as well as MRI scan

• MRI has greater tissue contrast resolution than CT.

• Better to perform MRI >48 hours after trauma and in patients with arteriovenous malformations (AVMs) or tumor

• Study of choice when looking for lesions in the posterior fossa

• Less radiation exposure compared with CT

• According to the Quality Standards Subcommittee of the American Academy of Neurology, routine use of brain imaging is not warranted for adults with recurrent headaches that have been defined as migraines with no recent change in pattern, no history of seizure, and no other focal neurologic signs or symptoms.

Diagnostic procedure: Lumbar puncture (LP) to rule out subarachnoid hemorrhage from aneurysm; detects minor leaks, which occur in 39% of patients who later have ruptures. CT scans are negative in 55% of patients with minor leaks.

Consider the same diagnostic evaluation in athletes as in nonathletes, except in cases of trauma with an increased risk of intracranial bleed.

Workup should be complete when diagnosis is in question. This may include, but is not limited to, evaluation for drug abuse, hypertension, vascular lesions, neoplasms, intracranial bleeding, and psychiatric issues.

Be cognizant of “red flags” within the history or physical examination that should prompt further neurologic evaluation in the form of either imaging or other diagnostic procedures ( Box 39.1 ).