Flight-associated headaches-prevalence and characteristics

Risk factors for airplane headache: A multivariable logistic regression analysis in a population of career flight personnel

IntroductionAirplane headache (AH) is a lesser-known headache disorder that occurs during and is caused by air travel. Although considered rare and current prevalence figures vary widely, it potentially affects millions annually. Risk factors for AH have not yet been adequately investigated, and so the present study aimed to identify risk factors associated with AH among a large cohort of frequent flyers.MethodsWe conducted a survey using an extensive questionnaire that highlighted 30 potential risk factors for AH. We compared individuals experiencing AH with those without headaches and those with other types of headaches. Two multivariate logistic regression models were developed from risk variables and assessed using the area under the curve (AUC) of their receiver operating characteristics, with 10-fold cross-validation applied for reliability.ResultsIn total, 2237 questionnaires were analysed; 279 participants reported aircraft headache, while 1563 reported other forms of headache. Model selection resulted in two significant models: model 1, distinguishing AH from no headache, and model 2, differentiating AH from other headaches. Both models demonstrated promising accuracy, with AUC values of 0.794 and 0.595, respectively.ConclusionsAH notably affects productivity and workdays lost. The identified risk factors align with risk factors for headache in general, as well as headache at high altitudes. Interestingly, folic acid supplementation could have a positive, protective effect. Further research is warranted to explore these relationships and potential preventive strategies.

Efficacy of a long-term acting triptan for Headache attributed to aeroplane travel: a case report

Headache attributed to aeroplane travel (AH) is a well-defined nosological entity whose diagnostic criteria have been published in the third provisional International Classification of Headache Disorders (ICHD) and confirmed in the definitive version. Despite the severe intensity of pain, less than half of the AH cases described used medications for preventing the attack. The most frequent prophylactic therapy spontaneously used by sufferers are simple analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), and nasal decongestants, achieving a complete or partial benefit in about 50% of patients. A complete response of AH to fast-acting triptans has been reported. We describe the case of a 37-year-old migrainous woman suffers from AH in about 75% of her flights who preempted the attacks by using a long-acting triptan (frovatriptan). Giving triptans' mechanism of action, an involvement of the trigemino-vascular system in the pathogenesis of AH could be advanced.

The epidemiology of airplane headache: A cross-sectional study on point prevalence and characteristics in 50,000 travelers

BACKGROUND

The current knowledge on the epidemiology and clinical manifestation of airplane headache is mostly derived from case series and small cohort studies without evidence from large populations.

METHODS

This cross-sectional study was conducted over a five-month period in the arrival area of two international airports in Germany. 50,000 disembarking passengers were addressed about headaches during their flight to determine headache prevalence, and those confirming and willing to participate underwent a structured interview.

RESULTS

Headache during travel was reported by 374 passengers (0.75%), and 301 underwent a structured interview. One hundred and one (0.2%) met the diagnostic criteria of airplane headache. Six passengers suffered from migraines and 134 from tension-type headaches. The differences in the age and gender distribution between the airplane headache and non-airplane headache groups were not statistically significant. The onset (79.2%), duration (82.2%), and location (73.3%) of airplane headache mostly complied with current diagnostic criteria but pain intensity (42.6%) and quality (42.6%) did less so.

CONCLUSION

Our data suggest a substantially lower prevalence of airplane headaches than previously reported. The pain intensity and quality seem less characteristic than assumed, suggesting a need to refine the current diagnostic criteria.

Sinus Barotraumas in Commercial Aircrew

BACKGROUND: Sinus barotraumas are a common condition in aviation medicine, sometimes compromising flight safety and even permanently grounding aircrew. Considering this and the ever-increasing amount of commercial aviation, a thorough examination is required.METHODS: In this survey study, an anonymous, electronic questionnaire was distributed to commercial aircrew of the three major commercial airlines operating in Finland (N 3799), covering 93% of the target population (i.e., all commercial aircrew operating in Finland, N 4083). Primary outcomes were self-reported prevalence, clinical characteristics, and health and occupational effects of sinus barotraumas in flight. Secondary outcomes were adjusted odds ratios (OR) for frequency of sinus barotraumas with respect to possible risk factors.RESULTS: Response rate was 47% (N 1789/3799), with 61% (N 1088) of the respondents having experienced sinus barotraumas in flight. Of those affected, 59% had used medications, 18% had undergone surgical procedures, and 53% had been on sick leave due to sinus barotraumas (38% during the last year) in flight. Factors associated with sinus barotraumas were female sex [OR, 2.47; 95% confidence interval (CI) 1.354.50] and a high number of upper respiratory tract infections (3 vs. <3 URTIs/yr: OR, 3.61; 95% CI 2.654.93).CONCLUSION: Sinus barotraumas were reported by 61% of commercial aircrew. They caused an increased need for medications, otorhinolaryngology-related surgical procedures, and sickness absence from flight duty. The possible risk factors were female sex and a high number of URTIs/yr.Lindfors OH, Ketola KS, Klockars TK, Leino TK, Sinkkonen ST. Sinus barotraumas in commercial aircrew. Aerosp Med Hum Perform. 2021; 92(11):857-863.

Craniofacial sensations induced by transient changes of barometric pressure in healthy subjects – A crossover pilot study

Background:

Changes in atmospheric pressure are suggested to trigger headaches. This pilot study was made to determine craniofacial sensations accompanying short phases of changing barometric pressure.

Methods:

In a crossover design, 15 adult healthy subjects were exposed in a climate chamber to 8 min phases of barometric pressure lowering by 0, 20 and 40 hPa. The subjects rated their sensations of ear pressure, head compression and the occurrence of headache every minute on a visual analogue scale (VAS, range 0–10). Pulse rate was recorded as a parameter for autonomic functions.

Results:

Nearly all subjects experienced ear pressure and half of them compression of their head at variable degrees. These sensations started in most subjects during the phase of lowering barometric pressure and increased to an average rating of about 3 VAS when returning to ambient atmospheric pressure. Heart rate slightly decreased during this phase. Three subjects reported mild to moderate headache for various durations within these phases.

Conclusions:

Changes in barometric pressure can be associated with sensations of ear pressure and head compression and may trigger headaches. The generation of these sensations is discussed with regard to convergent trigeminal innervation of the ear, the paranasal sinuses and the cranial meninges.

Headache Attributed to Aeroplane Travel: An Historical Outline

INTRODUCTION

Headache attributed to aeroplane travel (AH) is one of the new nosological entries in the International Classification of Headache Disorders (ICHD) 3 beta.

MATERIALS AND METHODS

This study retraces the history of headache related to flight, from the initial description to the modern reports, on the basis of original sources.

RESULTS

Head pain related to flight has been reported since the beginning of flight era. However, most of those early cases are easily recognized as secondary to an exceptional barotrauma and/or a sinusitis concomitant with the flight. Instead, contemporary research identified a new nosological entity, AH, which by definition occurs in normal flying conditions and in absence of any sinus pathology. Moreover, we identified recently similar forms of headache, triggered by sudden changes of external pressure (rapid descent from mountain, mountain descent headache, MDH); and ascent from diving, diving ascent headache (DAH).

CONCLUSION

Head pain related to flight has been reported since the origin of aviation, but it was caused by an exceptional barotrauma or a respiratory infection. Instead, AH occurs in normal flying conditions. Two newly identified conditions, MDH and DAH, appear to share a common pathogenetic mechanism with AH: namely the imbalance between intrasinusal and external air pressure. Therefore, we assert that an expansion of this entity of AH is something that should be considered in the next ICHD.

The Influence of Weather on the Incidence of Primary Spontaneous Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage has been associated with changes in various weather conditions. The primary aim of this study was to examine the collective influence of temperature, barometric pressure, and dew point temperature on the incidence of primary spontaneous intracerebral hemorrhage (sICH).

METHODS

Between January 2013 and December 2016, patients with sICH due to hypertension or amyloid angiopathy with a known time of onset were identified prospectively. Meteorological variables 6 hours prior to time of onset were obtained from the National Oceanic Atmospheric Administration via two weather stations. Using a Monte-Carlo simulation, random populations of meteorological conditions in a 6-hour time window during the same years were generated. The actual meteorological conditions 6-hours prior to sICH were compared to those from the randomly generated populations. The false discovery rate method was used to identify significant meteorological variables.

RESULTS

Time of onset was identified in 455 of 603 (75.5%) patients. Distribution curves for change in temperature, mean barometric pressure, and change in barometric pressure 6-hours prior to hemorrhage ictus were found to be significantly different from the random populations. (FDR approach P < .05). For a given change in temperature associated with intracerebral hemorrhage, mean barometric pressure was higher (1018 millibar (mb) versus 1016 mb, P = .03). Barometric pressure data was not influenced by variations in temperature.

CONCLUSIONS

We concluded that barometric pressure primarily influences the incidence of intracerebral hemorrhage. The association described in the literature between temperature and intracerebral hemorrhage is likely confounded by variations in barometric pressure.

Headache attributed to airplane travel: diagnosis, pathophysiology, and treatment - a systematic review

BACKGROUND

Headache attributed to airplane travel, also named "airplane headache" (AH) is a headache that occurs during take-off and landing. Today, there are still uncertainties about the pathophysiology and treatment of AH. This systematic review was performed to facilitate identification of the existing literature on AH in order to discuss the current evidence and areas that remain to be investigated in AH.

METHODS

The systematic literature search was performed in 3 relevant medical databases; PubMed, Scopus, and Embase. The search yielded 220 papers and the papers were sorted based on inclusion and exclusion criteria established for this study.

RESULTS

This systematic review included 39 papers. Main findings revealed that AH attacks are clinically stereotyped and appear mostly during landing phases. The headache presents as a severe painful headache that often disappears within 30 min. The pain is unilateral and localized in the fronto-orbital region. Sinus barotrauma has been considered as the main cause of AH. Nonsteroidal anti-inflammatory drugs and triptans have been taken by passengers with AH, to relieve the headache.

CONCLUSIONS

Based on this systematic review, further studies seem required to investigate underlying mechanisms in AH and also to investigate the biological effects of nonsteroidal anti-inflammatory drugs and triptans for alleviating of AH. These studies would advance our understanding of AH pathogenesis and potential use of treatments that are not yet established.

Simulated airplane headache: a proxy towards identification of underlying mechanisms

BACKGROUND

Airplane Headache (AH) occurs during flights and often appears as an intense, short lasting headache during take-off or landing. Reports are limited on pathological mechanisms underlying the occurrence of this headache. Proper diagnosis and treatments would benefit from identification of potential pathways involved in AH pathogenesis. This study aimed at providing a simulated airplane headache condition as a proxy towards identification of its underlying mechanisms.

METHODS

Fourteen participants including 7 volunteers suffering from AH and 7 healthy matched controls were recruited after meeting the diagnostic and safety criteria based on an approved study protocol. Simulation of AH was achieved by entering a pressure chamber with similar characteristics of an airplane flight. Selected potential biomarkers including salivary prostaglandin E₂ (PGE₂), cortisol, facial thermo-images, blood pressure, pulse, and saturation pulse oxygen (SPO) were defined and values were collected before, during and after flight simulation in the pressure chamber. Salivary samples were analyzed with ELISA techniques, while data analysis and statistical tests were handled with SPSS version 22.0.

RESULTS

All participants in the AH-group experienced a headache attack similar to AH experience during flight. The non-AH-group did not experience any headaches. Our data showed that the values for PGE₂, cortisol and SPO were significantly different in the AH-group in comparison with the non-AH-group during the flight simulation in the pressure chamber.

CONCLUSION

The pressure chamber proved useful not only to provoke AH-like attack but also to study potential biomarkers for AH in this study. PGE₂, and cortisol levels together with SPO presented dysregulation during the simulated AH-attack in affected individuals compared with healthy controls. Based on these findings we propose to use pressure chamber as a model to induce AH, and thus assess new potential biomarkers for AH in future studies.

Headaches attributed to airplane travel: a Danish survey

Background

Airplane headache (AH) is a headache that occurs during take-off and landing. The pain is described as severe, unilateral, and located in the fronto-orbital region. This study aimed at investigating the incidence of AH among Scandinavian air-travelers, and to elucidating potential risk factors.

Methods

An online, Danish-survey was developed. The questionnaire consisted of 14 questions and was distributed through the Facebook-pages of Scandinavian-airlines and interest organizations. Participants reached the questionnaire through a web-link.

Results

Out of 254 responses, 89 noted that they suffered from headaches associated to airplane travel. Of the 89, 21 cases the headache was severe and limited to 30 min duration, as described in the ICH’s criteria of AH. The remaining 68 cases indicated that the headache lasted longer than 30 min. Our data demonstrated that High-Altitude Headache (HAH) is a risk factor for developing AH (p < 0.05). Triptans (19 %) and paracetamol (5 %) were reported effective to relieve AH.

Conclusion

This study indicates that up to 8.3 % of the studied population suffered from AH, with a higher incidence in those with a history of HAH. Self-medication by triptans and paracetamol were reported effective for relieving AH.

An overview of travel-associated central nervous system infectious diseases: risk assessment, general considerations and future directions

Nervous system infections are among the most important diseases in travellers. Healthy travellers might be exposed to infectious agents of central nervous system, which may require in-patient care. Progressive course is not uncommon in this family of disorders and requires swift diagnosis. An overview of the available evidence in the field is, therefore, urgent to pave the way to increase the awareness of travel-medicine practitioners and highlights dark areas for future research. In November 2013, data were collected from PubMed, Scopus, and Web of Knowledge (1980 to 2013) including books, reviews, and peer-reviewed literature. Works pertained to pre-travel care, interventions, vaccinations related neurological infections were retrieved. Here we provide information on pre-travel care, vaccination, chronic nervous system disorders, and post-travel complications. Recommendations with regard to knowledge gaps, and state-of-the-art research are made. Given an increasing number of international travellers, novel dynamic ways are available for physicians to monitor spread of central nervous system infections. Newer research has made great progresses in developing newer medications, detecting the spread of infections and the public awareness. Despite an ongoing scientific discussion in the field of travel medicine, further research is required for vaccine development, state-of-the-art laboratory tests, and genetic engineering of vectors.

Diagnosis and management of headache attributed to airplane travel

The headache attributed to airplane travel, also named "airplane headache", is characterized by the sudden onset of a severe head pain exclusively in relation to airplane flights, mainly during the landing phase. Secondary causes, such as upper respiratory tract infections or acute sinusitis, must be ruled out. Although its cause is not thoroughly understood, sinus barotrauma should be reasonably involved in the pathophysiological mechanisms. Furthermore, in the current International Classification of Headache Disorders, rapid descent from high altitude is not considered as a possible cause of headache, although the onset of such pain in airplane travellers or aviators has been well known since the beginning of the aviation era. On the basis of a survey we conducted with the courteous cooperation of people who had experienced this type of headache, we proposed diagnostic criteria to be added to the forthcoming revision of the International Classification of Headache Disorders. Their formal validation would favour further studies aimed at improving knowledge of the pathophysiological mechanisms involved and at implementing preventative measures.

Headache attributed to airplane travel ('airplane headache'): clinical profile based on a large case series

BACKGROUND

The 'headache attributed to airplane travel', also named 'airplane headache' (AH), is a recently described headache disorder that appears exclusively in relation to airplane flights, in particular during the landing phase. Based on the stereotypical nature of the attacks in all reported cases, we proposed provisional diagnostic criteria for AH in a previously published paper. Up to now 37 cases have been described in the literature.

METHODS

After our paper was disseminated via the Internet, we received several email messages from subjects around the world who had experienced such a peculiar headache. Their cooperation, by completing a structured questionnaire and allowing the direct observation of three subjects, enabled us to carry out a study on a total of 75 patients suffering from AH.

RESULTS

Our survey confirmed the stereotypical nature of the attacks, in particular with regard to the short duration of the pain (lasting less than 30 minutes in up to 95% of the cases), the clear relationship with the landing phase, the unilateral pain, the male preponderance, and the absence of accompanying signs and/or symptoms. It is conceivable to consider barotrauma as one of the main mechanisms involved in the pathophysiology of AH. The observation that the pain appears inconstantly in the majority of cases, without any evident disorder affecting the paranasal sinuses, could be consistent with a multimodal pathogenesis underlying this condition, possibly resulting in the interaction between anatomic, environmental and temporary concurrent factors.

CONCLUSIONS

This is by far the largest AH case series ever reported in the literature. The diagnostic criteria that we previously proposed proved to be valid when applied to a large number of patients suffering from this condition. We support its recognition as a new form of headache, to be included in the forthcoming update of the International Headache Society Classification, within '10. Headache attributed to disorder of homoeostasis'. Its formal validation would favour further studies aimed at improving the understanding of its pathophysiology and implementing preventative measures.

Airplane headache: a further case report of a young man

Headache with normal examinations and imaging, occurring during an airplane flight has been rarely reported. We present a young patient with a new type of headache that appeared during flights: take-off and landing of a plane and was not associated with other conditions. This airplane headache is rather rare in population and the pathophysiology of this type is not clear. Secondary causes must be ruled out before the diagnosis of a primary headache is made.