Exercise Induced Headaches & Migraines- Causes & Observations
Even after all these years, the pain is still easy to recall: I was finishing up my last set of bench presses- a skinny but enthusiastic teen who had just started weight training a mere three weeks before, when it hit. In the final throes of my last set, pushing as hard as I could to overcome the forces of gravity I felt a sudden pain on the right side of my head. I finished the set and the workout, but as I kept going I felt the pain growing and growing in intensity. With every repetition sending a searing pulse of what can only be described as bright white pain shooting through my temples. At the end of the workout, my coach asked me if I was alright. In typical male machismo fashion, I nodded that all was well and went my way. I was no stranger to pain. Some would even say that I courted it, given the extreme nature of my martial arts training and my newly found love of weight training. But this was something that I was not ready for, a pain that reached into the depths of my being, and it took everything I had to walk the ½ mile home from the gym under the hot tropical sun. These headaches persisted for what seemed to be an eternity- but lasted only about a month. In the midst of training, it would strike, narrowing my vision with a haze of pain that would descend upon me. A pain that could only be soothed by the darkness of my room and the blissful release that sleep would bring. I began to worry that there was something wrong with me, and that perhaps I couldn’t keep on training the way I did. My goal of transforming myself from a lanky 125lber into a statuesque natural bodybuilder seemed further and further away with every throb of my skull- and yet as suddenly as it started, the headaches just stopped. This phenomenon, which I would later learn was a classic case of exercise induced migraine wasn’t a curse that had befallen me for some unacknowledged transgression, but rather a bane that affects many who engage in intensive physical activity.
Exercise Induced Headaches & Migraines- What Are They?
Exercise induced headaches and migraines have been diagnosed since the time of Hippocrates and yet we still know little about its causes. Often called ‘weightlifter’s headache’, it is associated with intense physical activity- especially unaccustomed levels of exertion. Clinically, these headaches fall into two major groups- exercise induced migraines or effort-exertion headaches.[2,3] Strict classification of headaches in one particular group presents significant diagnostic challenges as individuals can often have symptoms that can appear to fit several categories at the same time and many experts criticize the practice of strict categorization. Head trauma is a significant causative factor in sports related injuries and represent a very distinct group of sport related headaches. However, for the purpose of this article, we restrict our focus to the phenomenon of non-trauma related headaches.
Category 1- Exercise or Sports Induced Migraines
Exercise related migraine headaches usually have the following symptoms:
1. An aura, or visual or sensory warning before the onset of the headache
2. A pounding or throbbing headache of significant intensity lasting several hours.
3. A headache that is confined to one side of the head.
4. Nausea and or vomiting associated with the headache
Exercise related migraines tend to happen more than once and in many cases is a family history of such headaches as well.
Exercise Induced Migraine Headaches – Apparent Causes
As common as exercise induced migraines may be, we still don’t have a concrete understanding of why and how it happens. Exercise induced migraines tend to be more common in women than in men and the prevailing theory is that it may have some connection to low oxygen levels.[4,5] The low oxygen theory is commonly accepted as symptoms not only appear to be similar in nature to altitude sickness related migraines, but also due to the prevalence of exercise induced migraines among athletes during the 1968 Summer Olympics in Mexico City. A location 7,000 feet above sea level. At sea level such headaches are rare among highly trained athletes which suggests low oxygen levels as a possible trigger. While we are at this point unable to pinpoint the exact cause of exercise induced migraines, there are several factors that have been recognized as aggravating factors.
Exercise Induced Migraine: Aggravating Factors
1. Dehydration and inadequate water intake before strenuous physical activity
2. Hypoglycemia brought on from inadequate nutrition before intense exercise
3. Extreme exercise
4. Exertion at high altitudes
5. Exercise in high temperatures[6,7]
Exercise Induced Migraine: Treatments And Recommendations
Proper hydration can play a key role in avoiding exercise induced headaches
In my personal training practice, where high intensity training protocols call for training at near or beyond the point of momentary muscular failure, 1% of trainees (2 individuals over the course of three years) experienced migraine type headaches- usually within their first month of training. This data comes from a fairly large group of 296 people. Interestingly enough, and in line with my personal experience, symptoms subsided within a period of two months. Increased water intake before training as well and adequate pre-workout nutrition is recommended to avoid exercise induced migraines and may account for the cessation of symptoms among clients. Dietary and water intake are regulated among all who train within our system and improvements in adherence corresponded with the reduction of exercise induced migraines. All who suffered from exercise induced migraines self-reported that they did not drink anywhere near the amounts of water recommended on days that the headaches occurred and it is easy to hold these factors as being causative. However’they may simply be correlative as reduced incidence of migraines may also be a result of physiological adaptations to high intensity training as trainees increase their levels of fitness and tolerance to high levels of exertion. Thus, there is no real way to discern what factor actually caused the exercised induced migraines to stop and it bears noting that in only one case was exercise induced migraines clinically diagnosed by a physician. Longer warm up periods have also been recommended as a way of minimizing exercise induced migraines and is often effective as well.
Category II: Exercise Induced/Effort-Exertion Headaches
Effort-exertion headaches are the most common and most diverse of the subgroups of exercise related headaches, and like exercise induced migraines they tend to occur more among women than men. Exertion type or exercise induced headaches appear to occur after strenuous lifting, bending over, running and physical jarring but can also occur after sneezing, coughing and sexual intercourse. Such headaches tend to have the following symptoms:
1. A sudden acute headache that lasts for several seconds to as long as several hours as a result of physical exertion, but without visual or sensory cues beforehand.
2. A gradual headache lasting an hour or longer 
3. Pain in the occipital and neck region lasting only a few minutes in duration [9,10]
Exercise Induced/Effort-Exertion Headaches- Possible Causes
Sudden exertion headaches are usually caused as a result of strenuous anaerobic activity like intense weight lifting or sprinting, whereas the gradually building headaches tend to come after more sustained aerobic effort and fatigue. Like exercise induced migraines, the pathogenesis of exercise induced headaches remains unidentified but there are several theories that have been put forward. The possible causes include increased intrathoracic pressure[11,12], compression of blood vessels due to muscular tension[12,13], vasodilation of cerebral blood vessels as a response to stress, neck muscle tension and or strain, stimulation of nerve cells or fibers that transmit nerve impulses via monoamine neurotransmitters or a combination of these factors. While pathogenesis remains speculative there are some clearly defined factors that appear to trigger exercise induced headaches- factors that are listed below:
Exercise Induced Headache: Aggravating Factors
- Poor fitness levels
- Hot workout environments
- Extreme exercise or exertion
- Hypoglycemia due to inadequate pre-workout nutritional intake
- Alcohol and caffeine consumption [6,7,18]
Exercise Induced Headaches- Observations And Commonly Recommended Treatments
In my personal training practice, occurrence of acute exercise induced headaches was slightly higher than that of exercise induced migraines- 1.7% as opposed to 1% (a total of 2 trainees self reporting exercise induced migraines and 5 self reporting exercise induced exertion headaches). However, caution must be exercised when comparing these numbers since they are merely casual observations as no formal clinical diagnoses were made in each case. The symptoms of exercise induced headaches mimic that of many other potentially serious neurological disorders and self diagnosis should never be relied upon. That being said, about those who did experience exercise induced headaches at one point or another usually did so early on in their training as well. Self-reported among those who experienced the headaches was consumption off caffeinated drinks pre-workout, inadequate water intake, skipping breakfast and lack of sleep. Like exercise induced migraines, the headaches never persisted among 4 out of 5 who suffered from the headaches. The 5th trainee has only experienced self reported exercise induced headaches for just about a month, however those headaches appear to be decreasing intensity in keeping with the pattern experienced by other trainees whose headaches tended to go away gradually. For those who continued to exercise the headaches usually subsided no longer than one to two months after they began- becoming less and less intense with every occurrence. It is again hard to say what causes the improvement and without clinical verification all observations are speculative at best. However, all who experienced the headaches either stopped drinking coffee, increased their water intake and or made sure that they did not skip breakfast and ate adequate amounts of carbohydrates and fats to fuel their high intensity workouts. Again, these factors may be simply correlative as the increased fitness levels and adaptations to exercise that occur over time may be ultimately responsible or perhaps a combination of all of the aforementioned factors.
A Clinically Viable Method To Stop Exercise Induced Headaches & Migraines
Caffeine is widely consumed around the world in both food and beverages, and it has been shown to have some considerable effect on stopping migraines. As a personal trainer, it is not my place nor practice to recommend the use of any type of drug, however I did come across the use of a particular protocol for the treatment of exercise induced migraines. The book, Where There Is No Doctor has always been a constant companion of mine, and it is a has been a standard among health care workers across the globe for decades. The protocol described to stop a migraine is as follows:
- Take 2 aspirin with a cup of strong coffee or strong black tea
- Lie down in a dark quiet place, relax 
That said, I did have an online client who complained of headaches immediately after his high intensity weight training sessions and he asked if there was anything I could recommend. I suggested that he consult his physician about the use of caffeine and aspirin as a possible aid and he brought it to his doctor’s attention. She agreed that there was no evidence of any harm coming from it and that it did show some efficacy in several studies  and so the next time he had a headache coming on after a workout, he had some coffee with 2 aspirin and retired to a dark place. Miraculously, the headache went away and did so on two more occasions when he did the same thing upon the first onset of symptoms. This was not known in my time, but research now shows that combining caffeine with over the counter analgesic medications, such as acetaminophen, aspirin, and ibuprofen, significantly improves relief of migraine headaches and more so than the use of an over the counter painkiller on its own.[21,22,23,24,25,26] however it would appear that the treatment works best when it is used immediately as symptoms begin to present themselves.
Aside from increasing fitness levels over time, the best treatments for exercise related headaches and migraines are proper sleep to minimize fatigue, good nutrition, adequate hydration and an extended warm up period. Other suggested treatments include keeping a journal of headaches as a way to pinpoint the causative factors- a method I undertook myself but thankfully my migraines stopped before I had a chance to record much of anything. Pharmacological solutions are often suggested as well, however it is recognized in the medical community that there is a need for more large scale studies of athletes who suffer from these headaches. Not only to identify the mechanisms of pathogenesis but also for the creation of standardized treatment protocols.  Either way, given the substantial benefits of physical exercise and activity, unless you are advised otherwise by a physician, it is important that you do your best to keep exercising whenever possible . Be sure to always consult your physician about any recurring headaches you may experience even if you believe that they may simply be exercise induced. There is no such thing as being too safe.
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