Headaches and exercise

The Experience of Post-Stroke Pain and The Impact on Quality of Life: An Integrative Review

Background: Many people experience post-stroke pain (PSP). It is a long-term consequence of stroke that commonly goes unrecognised and untreated. As a result, an integrative review is needed to identify the primary factors that affect PSP and determine the impact on quality of life (QOL). Methods: An integrative review using a quantitatively led data synthesis, supported by qualitative evidence, was conducted. Results: Fourteen studies were identified and 2415 (968 females, 1447 males) people were included. Five primary themes were identified as effecting the experience of PSP; anxiety, depression, fatigue, cognitive function and physical function. Anxiety, depression and fatigue increase PSP. Pain, depression, fatigue and reduced physical function lower QOL. Conclusions: It is essential that clinicians recognise PSP in order to optimize QOL and function post-stroke. Further research is needed to employ a strategy to identify and objectively quantify PSP and its impact on QOL.

Aerobic Exercise and Plasma Beta Endorphin Levels in Patients with Migrainous Headache Without Aura

This study aims to evaluate the effects of plasma beta endorphin level and exercise on migrainous headache. Forty patients with migrainous headache without aura (MWOA), firstly exercised on a treadmill and afterwards were asked to continue an aerobic home exercise program for six weeks. On evaluation, basal plasma beta endorphin level was negatively correlated with total duration of attacks in the last month period ( P = 0.01). Exercise was found to have beneficial effects on all migraine parameters ( P < 0.0001) and to increase beta endorphin levels after the treadmill practice ( P < 0.0001) and after the home exercise program except four patients not regularly attended to the program ( P < 0.0001). Any of the changes in headache parameters was not correlated with the change in beta endorphin level. However, pre-exercise beta endorphin level was found to be negatively correlated with the changes in the number of attacks ( P < 0.05) and total duration of attacks ( P = 0.01) and also with the change in beta endorphin level due to exercise ( P < 0.0001). As a result, this study emphasizes the beneficial effect of exercise on migrainous headache, especially in patients with lower basal beta endorphin level.

Sports Neurology in Clinical Practice: Case Studies

With regard to persistent posttraumatic headache, there is legitimate concern that duration of symptoms may have an impact on the efficacy of future treatment attempts. Without neuropathologic confirmation, a clinical diagnosis of chronic traumatic encephalopathy cannot be made with a high degree of confidence. Sport-related headaches are challenging in a return-to-play context, because it is often unclear whether an athlete has an exacerbation of a primary headache disorder, has new-onset headache unrelated to trauma, or is in the recovery phase after concussion. Regular physical exercise may prove beneficial to multiple neurologic disease states.

The Prevalence of Headache Among Athletic University Students

Background:

Headache is certainly one of the most common medical complaints of general population and one of the important causes of consumption of drugs. Despite its high overall prevalence, the epidemiology of exertional headache is not clear enough.

Objectives:

To determine the prevalence of headache in athletic and non-athletic university students and also estimating its variation between different sports fields including concussion prone sports.

Materials and Methods:

This cross-sectional study comprised 739 subjects (367 athletes and 372 non-athletes). The present study was carried out on athletic and non-athletic university students aging between 18 to 28 years. An athlete was defined as a person who had at least one year of experience in sports including football, volleyball, basketball, wrestling, boxing, martial arts, track and field, chess, handball and swimming for three sessions a week each lasting at least 2 hours. The random selection of these participants was done by an independent statistical consultant. A questionnaire was used for data collection which was then analyzed by statistical methods.

Results:

Our study comprised 739 subjects (367 athletes and 372 non-athletes). Among athletic university students, 152 (41.2%) participants complained of headache. Such a complaint was present in 217 (58.3%) non-athletic university students. This lower prevalence of headache in athletes was statistically significant (P value < 0.001). Among ten different sports fields, the prevalence of headache among wrestlers was significantly higher than others (P value < 0.001).

Conclusions:

The prevalence of headache is seemingly lower in athletic university students than non-athletic ones. In addition, among athletes, those who are participating in concussion prone sports especially wrestling experience headache more than athletes of other fields.

Headache in sports

Sports- and exercise-related headaches are not unusual. Despite their frequent occurrence in this context, there are little epidemiologic data concerning sports-related headache. The recent attention of concussive injuries and associated post-traumatic headache has renewed interest in the study of those headaches occurring after head trauma; however, any primary headache type can also occur in the setting of contact and/or collision sports. The nonspecific nature of headaches provides unique challenges to clinicians encountering this complaint. It is, therefore, imperative that physicians treating athletes are able to distinguish the various headache types and presentations often seen in this population.

Migraine headache confounding the diagnosis of acute mountain sickness

A 36-year-old man with a history of migraine headache attempted to hike from Lukla, Nepal, to Mount Everest Base Camp. On the sixth day of hiking, he had a migraine headache. After achieving resolution with typical therapies and rest, he ascended higher. Another headache developed that was interpreted to be a migraine. The headache was treated, and he ascended higher, after which severe symptoms of acute mountain sickness developed, necessitating his evacuation by helicopter. Persons with headaches in daily life may present challenges to diagnosis when traveling to high altitude. Careful evaluation and decision making are needed to achieve proper diagnosis and treatment of acute mountain sickness.

Conservative physical therapy management for the treatment of cervicogenic headache: a systematic review

PURPOSE

The purpose of this systematic review was to assess the effectiveness of conservative physical therapy management of cervicogenic headache (CGH).

INTRODUCTION

CGH affects 22-25% of the adult population with females being four times more affected than men. CGHs are thought to arise from musculoskeletal impairments in the neck with symptoms most commonly consisting of suboccipital neck pain, dizziness, and lightheadedness. Currently, both invasive and non-invasive techniques are available to address these symptoms; however, the efficacy of non-invasive treatment techniques has yet to be established.

METHODS

Computerized searches of CINAHL, ProQuest, PubMed, MEDLINE, and SportDiscus, were performed to obtain a qualitative analysis of the literature. Inclusion criteria were: randomized controlled trial design, population diagnosed with CGH using the International Headache Society classification, at least one baseline measurement and one outcomes measure, and assessment of a conservative technique. Physiotherapy evidence-based database scale was utilized for quality assessment.

RESULTS

One computerized database search and two hand searches yielded six articles. Of the six included randomized controlled trials, all were considered to be of 'good quality' utilizing the physiotherapy evidence-based database scale. The interventions utilized were: therapist-driven cervical manipulation and mobilization, self-applied cervical mobilization, cervico-scapular strengthening, and therapist-driven cervical and thoracic manipulation. With the exception of one study, all reported reduction in pain and disability, as well as improvement in function.

CONCLUSION

Calculated effect sizes allowed comparison of intervention groups between studies. A combination of therapist-driven cervical manipulation and mobilization with cervico-scapular strengthening was most effective for decreasing pain outcomes in those with CGH.

Subarachnoid hemorrhage of unknown etiology along the cortical convexity

BACKGROUND

Only 8% to 22% of cases of subarachnoid hemorrhage (SAH) are of nonaneurysmal origin. Among these, perimesencephalic nonaneurysmal SAH is a distinct clinical and radiologic entity with normal angiographic findings and a good prognosis. In contrast, SAH of nonaneurysmal origin occurring along the cortical convexity is rare and poorly understood. We report 2 cases of subarachnoid hemorrhage along the cortical convexity and discuss their possible etiologies.

METHODS

In a retrospective analysis of 234 patients with SAH, we identified 2 patients with a typical computed tomographic pattern of convexity SAH that was associated with no known etiology.

RESULTS

In these 2 cases, the source of hemorrhage could not be identified with computed tomography, magnetic resonance imaging, or digital subtraction angiography, although neurovascular outcomes were good. The patients reported such incidents as coughing or exertion immediately before headache developed. These incidents may have caused increased intracranial pressure.

CONCLUSION

We suggest the possible involvement of a brief increase in intracranial pressure, such as that accompanying coughing or exertion, in the occurrence of SAH along the cortical convexity.

Characteristics of Headache at Altitude among Trekkers; A comparison between Acute Mountain Sickness and Non-Acute Mountain Sickness Headache

Purpose

Headache at altitudes has had an incidence of 25-62% through many related studies. Many reasons are identified concerning headache at altitudes such as acute mountain sickness (AMS), sinus headache, migraine, tension type headache, and frontal tension headache. This study tried to compare different types of headache among trekkers on Mount Damavand, a 5671m mountain, Iran, to find their incidence and related symptoms and signs.

Methods

Through a cross-sectional study, we evaluated headache incidence and its correlation to AMS among people who climbed Mount Damavand. Lake Louise Score, a self-report questionnaire, was applied to make AMS diagnosis through three separate stages of trekking programs. Chi-square test was employed as the main mean of analysis.

Results

Totally, 459 between 13-71 year olds participated in the study among which females were 148 (32.1%) and males 311 (67.8%). Headache was found in 398 (86.7%) among whom 279 (70%) were proved as AMS. Investigating the types of headache in the cases of AMS showed 64.5% to be of steady, 31% throbbing and 4.5% stabbing characters which had significant differences with a P value = 0.003. The majority of headaches were stated as frontal (38.9%) and the least prevalence belonged to the parietal area (4.4%), while global headache was reported in 27%.

Conclusions

This study specifies the exact location of headaches at altitude in cases of AMS and non-AMS headaches. Many cases of high altitude non-AMS headache are resulted by tension and light reflection at altitude.

Migraine with aura in the locker room: three case reports

It is well known that physical activity can aggravate the intensity of the headache, but the pathophysiological relationship between exertion and aura is still unknown. Anecdotal reports describe episodes of migraine preceded by head trauma and visual symptoms, migraine prodrome symptoms after unusually strenuous running with no subsequent head pain or recurrent attacks of hemiplegic migraine induced only by exertion. We describe the cases of three young men with recurrent episodes of migraine with aura occurring in the locker room shortly after a football match. Since the symptoms could mimic important pathologies in approximately 10% of these of headaches, it was mandatory to exclude a secondary form of headache in these patients. Several theories exist regarding the cause of primary exertional headache, but the pathogenesis of migraine triggered by physical activity has still not been identified. The present International Classification of Headache Disorders does not mention sport/exercise-induced migraine with aura episodes as primary headache. Since there are many cases described in the literature of migraine with aura triggered only by exercise, it may be helpful to specify, in the typical aura with migraine headache comments, that in some cases it can be exclusively triggered by sport/exercise.

Risk factors for high-altitude headache in mountaineers

Aim: The aim was to identify most relevant risk factors of high-altitude headache within a broad mountaineering population through a prospective, observational, rater-blinded study.

Methods: A total of 506 mountaineers were enrolled after their first overnight stay in one of seven alpine huts between 2200–3817 m. Structured interview including information on mountaineering histories, caffeine intake, smoking habits, alcohol consumption, intake of medication, rate of ascent, physical fitness, the level of exertion and the amount of fluids intake at the day of ascent were recorded along with a standardized medical examination.

Results: High-altitude headache occurred in 31% of study participants. Logistic regression analysis revealed a migraine history, low arterial oxygen saturation, high ratings of perceived exertion and fluid intake below 2 l to be independent risk factors for the development of high-altitude headache.

Conclusion: Given the high prevalence, high-altitude headache is a relevant medical condition and a better understanding of risk factors has important impact and may facilitate patient behaviour and future study design.

[Exercise in migraine treatment. Review and discussion of clinical trials and implications for further trials]

Regular exercise is recommended in general treatment guidelines for migraine. However, scientific evidence in support of this recommendation is weak. The majority of available trials on this topic do not meet modern requirements for randomized clinical trials. Often the diagnosis of migraine is not certain, the duration of treatment is too short, and the intervention is not clearly defined; furthermore, the control of treatment is insufficient. The study results are controversial regarding the efficiency of sports intervention in migraine. Regular exercises may have specific effects on the course of disease in migraine through increase of fitness or relaxing effects. It remains unclear whether exercise alone is efficient in migraine treatment or only as part of a more multidisciplinary program. Theoretical considerations, the available limited studies, and clinical experience suggest that exercise may have an effect on migraine, but the present knowledge does not fulfill the needs of evidence-based medicine. Future studies should adhere to the rules for randomized clinical trials in pharmacological migraine prophylaxis.

Aerobic exercise with relaxation: influence on pain and psychological well-being in female migraine patients

OBJECTIVE

The objective of this pilot study was to address the influence of an aerobic exercise program combined with relaxation on pain and psychological variables in migraine patients.

DESIGN

Controlled, randomised design with half of the group receiving an intervention (aerobic exercise group) in addition to standard medical care received by all patients. SETTING/PATIENTS/OUTCOME MEASUREMENT: Thirty female migraine outpatients completed a range of psychological questionnaires measuring sensational and affective dimensions of pain, body image, depression, and quality of life.

INTERVENTION

The aerobic exercise group (n = 15) participated in a 6-week, twice-weekly, indoor exercise program (45 minutes of gymnastics with music and 15 minutes of progressive muscle relaxation).

RESULTS/CONCLUSION

The program led to a significant reduction of self-rated migraine pain intensity. Although there was an improvement in depression-related symptoms within the aerobic exercise group, no significant differences in psychological variables between groups were found.

Incompetence of Internal Jugular Valve in Patients with Primary Exertional Headache: A Risk Factor?

The pathophysiology of primary exertional headache (EH) is unknown. Physical exertion is associated with Valsalva-like manoeuvres (VM). VM leads to increased intrathoracic pressure and reduces cerebral venous drainage. Internal jugular vein valve incompetence (IJVVI) leads to retrograde venous flow during VM with transient increase of intracranial pressure. We analysed the prevalence of IJVVI in EH patients using duplex ultrasound. Bilateral measurements were performed at rest and during VM in 20 patients and 40 controls. Incompetence was concluded if retrograde venous flow could be seen in the jugular Doppler spectrum during repeated VM. Seventy percent of EH patients and 20% of controls demonstrated IJVVI, yielding a significant difference ( P = 0.0004). IJVVI was always observed on the dominant venous drainage side. Our study suggests that intracranial venous congestion caused by retrograde jugular venous flow might play a role in the pathophysiology of EH with IJVVI as a risk factor.

Open label study of intranasal sumatriptan (Imigran) for footballer's headache

OBJECTIVE

To study the efficacy and practicality of treating headache in professional footballers with intranasal sumatriptan.

METHODS

An open label drug trial was performed in elite Australian footballers using intranasal sumatriptan (20 mg) treatment for acute headache. The main outcome measures were treatment response at 30 minutes, two hours, and 24 hours using two criteria: (a) initial severity moderate or severe to nil or mild; (b) stricter criteria of initial severity moderate to severe to subsequent nil headache.

RESULTS

Thirty eight attacks were analysed. The two hour response showed that 86% of attacks of migraine with aura and all of the attacks of migraine without aura responded to treatment with sumatriptan nasal spray. Complete relief of headache at two hours was reported by 71% of players with migraine with aura and 90% of those without aura. Recurrence rates were generally low, with 0% of migraine headaches and 25% non-migraine attacks recurring at 24 hours. Minor side effects were reported in 28 attacks.

CONCLUSIONS

This pilot open label trial suggests that sumatriptan nasal spray may be a valuable, effective, and convenient treatment of headache in professional sport. There are potential risks of this drug that need to be considered.

Leisure activities in adolescents with headache

AIM

To investigate the association between different types of headache and leisure activities in 13-y-old schoolchildren.

METHODS

A population-based, cross-sectional study was performed through face-to-face interviews with age-matched cohorts with headache and asymptomatic controls. The present study comprised 59 children with migraine, 65 with episodic tension-type headache (TTHA) and 59 headache-free controls. In the interview, besides questions concerning headache, the children were asked open and structured questions about the type and amount of their leisure activities.

RESULTS

Children with migraine spent more time in sports activities than children with episodic tension-type headache or children without headache (test for trend, p<0.01; migraine: OR 1.4, 95% CI 1.1-1.9; tension-type headache: OR 0.9, 95% CI 0.7-1.1). The type of leisure activity was not significantly associated with headache type (p>0.05). Children with both migraine and episodic tension-type headache used computers more often than children without headache (test for trend, p<0.05; migraine: OR 1.2, 95% CI 1.1-1.5; tension-type headache: OR 1.3, 95% CI 1.1-1.5).

CONCLUSION

This study provides additional data on the activity status and headache complaints in adolescents. The results indicate that frequent computer use is associated with both tension-type headache and migraine, and intensive overall sports activities are characteristic of adolescents with migraine.

Prevalence of headache in Australian footballers

OBJECTIVE

To survey the prevalence and risk factors for headache in a population of elite professional Australian footballers.

METHODS

A prospective questionnaire based survey was performed on elite Australian footballers participating in a national competition. The survey was designed to assess the prevalence and risk factors for headache using standardised International Headache Society (HIS) criteria. Headache prevalence was compared with that of an age and sex matched community control population.

RESULTS

A total of 160 questionnaires were analysed. Headaches were reported by 80% of subjects, with 49% of respondents reporting headaches during competitive match play and 60% during training. There was no significant difference between the footballers and the community sample in the number of headaches ever; however, they did report more headaches in the three months before the survey--that is, during the competitive playing season. In the footballers, 22% of headaches conformed to the strict IHS definition of migraine headaches. When the relaxed definition of "footballer's migraine" was used, 34% of headaches met these criteria. Footballers were at significantly increased risk of footballer's migraine than community controls.

CONCLUSIONS

Headaches are common in Australian footballers, and the prevalence of migraine is increased in relation to community prevalence studies. Furthermore, the strict IHS criteria may not adequately identify the specific subtype of football related headache. This finding has important implications in the management of headache in this setting.

Sports-related headache

Sports-related or sports-associated headaches are common. They can be benign as in primary exertional headache or may signal serious pathology as in headache associated with traumatic subdural hematoma. Specific sports activities are associated with unique headache conditions such as decompression sickness headache or high-altitude headache, which mountain climbers experience along with other symptoms of chronic mountain sickness. The management of sports-related headaches requires an adequate understanding of its underlying etiology with subsequent cause-directed treatment plan.

Preparticipation assessment for head injury

OBJECTIVE

To determine the evidence base for recommendations regarding the pre-participation screening for head injury.

DATA SOURCES

The relevant literature was searched through the use of Medline (1966 to 2004), Google and Sport Discus (1975 to 2004) searches, hand searches of journals and reference lists and discussions with experts and sporting organisations worldwide.

DATA SYNTHESIS/METHODS

Consensus recommendations are summarized. No formal statistical analysis is presented

RESULTS

Although pre-participation examinations are widely performed, there are no evidence-based guidelines to direct physicians as to the minimum requirements for the baseline assessment of head injury.

CONCLUSIONS

Expert consensus would suggest that a baseline neuropsychological examination, preferably using a computerised test battery, should be performed in order to guide return to play following subsequent concussive injuries. In addition, there are important medicolegal considerations in regard to the value of a documented assessment both at the start and end of an athlete's career with any team.

Relationship between postconcussion headache and neuropsychological test performance in high school athletes

BACKGROUND

The relevance of headache to outcome after sports-related concussion is poorly understood.

HYPOTHESES

High school athletes reporting headache approximately 1 week after injury will have significantly more other concussion symptoms and will perform more poorly on neuropsychological tests than athletes not experiencing headache.

STUDY DESIGN

Prospective cohort study.

METHODS

Study participants included 109 high school athletes who had sustained concussion and who were divided into two groups: those reporting headache 7 days after injury and those reporting no headaches. The two groups were compared regarding on-field markers of concussion severity at the time of injury and symptoms and neurocognitive test results collected via ImPACT, a computerized neuropsychological test battery and postconcussion symptom scale, at a mean of 6.8 days after injury.

RESULTS

Athletes reporting posttraumatic headache demonstrated significantly worse performance on reaction time and memory ImPACT neurocognitive composite scores. These athletes also reported significantly more symptoms other than headache and were more likely to have demonstrated on-field anterograde amnesia.

CONCLUSIONS

Findings suggest that any degree of postconcussion headache in high school athletes 7 days after injury is likely associated with an incomplete recovery after concussion.

Benign exertional headache

We describe 4 patients with benign exertional headache presenting to the emergency department. Consideration of this uncommon cause of headache might facilitate an accurate diagnosis of those patients with headache caused by strenuous exercise.

2002 Refshauge Lecture. When to retire after concussion?

The management of an athlete with recurrent concussions, whether persistently symptomatic or not, remains anecdotal. There are no evidence-based guidelines upon which a team physician can advise the athlete. All doctors involved in athlete care need to be aware of the potential for medicolegal problems if athletes are inappropriately returned to sport prematurely or in the case of professional athletes held out of sport or retired on the basis of non-scientific recommendations.