Primary Exercise Headache

The Basics

Primary exercise headache, previously known as primary exertional headache, is a rare headache type brought on by or occurring only during or after physical exercise.

Primary exercise headache is termed “primary” because it’s not caused by another condition or disorder. People with new or never-evaluated exercise headache should be carefully assessed by their doctor for an underlying cause and considered for imaging of their brain and blood vessels to exclude conditions like brain tumor or another lesion that blocks the flow of spinal fluid, subarachnoid haemorrhage, arterial dissection and reversible cerebral vasoconstriction syndrome. People who have exercise-induced headache and cardiovascular risk factors (such as history of heart attack, coronary artery disease, diabetes, high blood pressure, high cholesterol, obesity, or smoking) should be evaluated for heart disease as a cause for their headache (cardiac cephalalgia), particularly if headache occurs only with exercise or the pain radiates to or from the neck or jaw.

Primary exercise headache is commonly described as bilateral (on both sides of head) and pulsating. Primary exercise headache generally lasts from five minutes to 48 hours. It may have similar features to migraine and must be distinguished from migraine triggered by exertion. Primary exercise headache is more likely to occur in hot weather or at high altitude, but can occur in any weather and at any altitude.

Please refer to the International Classification of Headache Disorders 3rd edition (beta version) website for more information on the criteria used to diagnosis primary exercise headache: https://www.ichd-3.org/other-primary-headache-disorders/4-2-primary-exercise-headache/

Treatment

Primary exercise headache is often self-limiting, which means that it occurs for a period of time, and then stops occurring. Primary exercise headache is often self-limiting to a period of three to six months. Given the self-limited nature of primary exercise headache, people should be advised to avoid excessive exercise or triggering activities if possible.

In cases where the headache is mild or builds slowly, warming up before exercising and/or an exercise program that begins slowly and increases in intensity and length over a period of months may prevent primary exercise headache.

Naproxen or Indomethacin taken 30-60 minutes before exercise may prevent primary exercise headache in some cases. However, with indomethacin and naproxen, treatment should be monitored to avoid stomach irritation. Beta-blockers such as nadolol and propranolol have also been reported to be effective for preventing primary exercise headache, and are reasonable options for people who cannot take naproxen or indomethacin. Since primary exercise headache is self-limiting, it’s suggested that treatments be discontinued after six months for reevaluation of their need.

Summary

Primary exercise headache occurs only during or after physical exertion. It is important to note that primary exercise headache is not the same as a migraine triggered by exertion. If exercise brings on a headache for you, it is important to see your doctor so more dangerous issues such as subarachnoid hemorrhage and vessel dissection can be ruled out. The good news is that primary exercise headache tends to be self-limiting and stops occurring after three to six months. A change in exercise regimen or addition of treatment can help prevent primary exercise headache.

Resources:

The International Headache Society. https://www.ichd-3.org/other-primary-headache-disorders/4-2-primary-exercise-headache/.

Halker RB, Vargas BB. Primary exertional headache: Updates in the literature. Curr Pain Headache Rep 2013;17:337-013-0337-8.