I’m very brave generally, he went on in a low voice: only today I happen to have a headache.
Tweedledum in Lewis Carroll’s Through the looking-glass, 1871
Headache has been called “the most common complaint of humanity,” affecting approximately two-thirds of the population. Athletes suffer from the same causes of headache as non-athletes. In addition, there are several causes of headache that relate directly to exercise. Numerous attempts have been made to classify the different types of headache. Headaches can be classified into seven groups, the first four of which are seen commonly, and the second three less commonly:
headache associated with viral illness (e.g. respiratory infections, sinusitis, influenza)
vascular headaches (e.g. migraine, cluster headache)
cervical headache (e.g. referred from joints, muscles, and fascia of the cervical region)
tension headache or muscle contraction headache
intracranial causes (e.g. tumor, hemorrhage, subdural hematoma, meningitis)
exercise-related headache (e.g. benign exertional headache, “footballers’ migraine”)
other causes (e.g. drugs, psychogenic, post-spinal procedure, post-traumatic).
Exercise-related and post-traumatic headache are of particular concern in sportspeople. While it is usually possible to differentiate between the groups, headaches of mixed type occur commonly.
The International Headache Society (IHS) (website at end of chapter), in conjunction with the World Health Organization (WHO), has proposed an overall classification for headache.1 While this classification system is used mainly for research purposes, it nevertheless provides a framework to assist in clinical management.
Although a few published studies have documented that headache is a frequent complaint in sportspeople (occurring in up to 85% of American footballers), relatively little systematic research or attempts at classifying sport-related headache have occurred to date.2 The IHS headache classification is problematic when applied in this setting and is of little use to the practicing clinician. Kernick and Goadsby have proposed a simplified organizational system that is of greater relevance when treating professional and amateur sportspeople:3
a recognized headache syndrome (e.g. migraine) coincidental to sporting activity
a recognized headache syndrome (e.g. migraine) induced by sporting activity
headache arising from mechanisms that occur during sport or exertion
headache related to changes in cardiovascular parameters
headache related to trauma
headache arising from structures in the neck
headache arising from mechanisms specific to an individual sport (e.g. goggle headache).
While this approach somewhat reflects the limited published data in the field, its classification does not fit easily either into the IHS categories nor into a sports physician’s clinical framework. As such, this new classification may need further conceptual development and validation through formal epidemiological studies.
Clinical approach to the patient with headache
The majority of headaches do not require medical assessment. However, certain symptoms may indicate the presence of more serious abnormalities and require medical assessment. These symptoms are:
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