Neurology

Headaches

15.1 Benign Exertional Headache

Clin Sports Med 1992;11:339

Cause: Excessive strain.

Epidem:

Athletes are susceptible at the same rate as the general population for headaches of all kinds (muscle tension, vascular, posttraumatic, etc).
In addition, there are several entities peculiar to certain athletes.

Pathophys: Due to decreased cerebral blood flow following exertion related increase in intracranial pressure via Valsalva effect.

Sx:

Sudden onset, severe pain in a rapid crescendo pattern w dull headache.
Usually occipital.
Pain is worsened with continued effort.

Si: Generally nonspecific.

Crs: Symptoms last from a few min to several hr.

X-ray:

CT or MRI recommended to rule out organic cause. Has been reported to be associated with structural lesion in up to 10% of cases.

Rx:

NSAIDs.
Biofeedback.
Activity modification.

15.2 Weightlifter’s Headache

Clin Sports Med 1992;11:339

Cause: Excessive straining.

Pathophys: Related to either increased intracranial pressure (Valsalva) or cervical ligament and tendon strain.

Sx: Sudden onset, severe and stabbing pain radiating from the base of the skull and proximal cervical spine to the parietal areas.

Si:

Point tender at base of skull and posterior cervical structures.
Painful ROM.
Neurologic exam normal.

Crs: Variable.

X-ray:

Cervical radiographs to rule out degenerative disease or structural anomaly.
CT or MRI to rule out mass lesion, vascular lesion or Arnold-Chiari malformation.

Lab: Lumbar puncture to rule out infectious cause.

Rx:

Analgesic measures: NSAIDS, cryotherapy, heat packs, analgesic medications, and massage.
Physical therapy for scapulothoracic dysfunction, and cervical strengthening.

15.3 Exertional Migraine (Acute Effort Migraine)

Clin Sports Med 1992;11:339

Cause: Arise with brief, high-intensity effort.

Pathophys:

Similar to migraine with hyperventilation leading to vasoconstriction (due to decreased pCO2) followed by reflex vasodilation and headache.
Contributing factors include: dehydration, exercising in extreme heat, poor nutrition, and alcohol consumption.

Sx:

May have prodrome.
Severe pain, short in duration.

Si: Negative exam.

Crs: Intense pain, short in duration.

Diff Dx: Other intense headache; intracranial mass, hemorrhage, infection, migraine.

X-ray: MRI indicated in general work-up of severe headache, but neg with acute effort migraine.

Rx:

Treat as for typical migraine; NSAIDs, sumatriptan, ergotamine, or midrin.
Prophylactic measures include; preexercise warm-up, good intra-session hydration practices, good sleep hygiene, gradual physical conditioning, and improved nutrition.
Prophylactic medications may be useful; calcium channel blockers, beta-blockers, amitriptyline, or low-dose ergotamine to name a few.

15.4 Jogger’s Migraine (Prolonged Exertional Headache)

Clin Sports Med 1992;11:339

Cause: Arises with endurance training, generally low intensity.

Epidem: More common with de-conditioned state, dehydration, hyperthermia, and poor nutrition.

Pathophys: Vascular headache triggered by gradual dehydration and heat accumulation.

Sx:

Gradual onset of throbbing type headache that is usually generalized or frontal.
Nausea, vomiting, and visual changes.

Si: Exam usually neg.

Crs: Symptoms may be prolonged in duration.

X-ray: CT or MRI to rule out vascular or structural lesion.

Rx:

Usually responds to NSAIDs.
Gradual conditioning program.
Ensure proper hydration and nutrition.
Avoid alcohol and caffeine.

15.5 Concussions (Traumatic Brain Injury-TBI)

Am Fam Phys 1999;60:887

Cause: Direct blow to head.

Epidem:

Approximately 15-20% of high-school football players sustain at least one concussion resulting in 250,000 TBI/yr.
Fourfold risk of sustaining a second TBI following initial concussion.
Most common in collision sports but can occur in any sport or activity.

Pathophys:

Mechanics of injury include both linear and rotational acceleration/deceleration (coup/contra-coup).
These forces probably result in microscopic axonal shear-strain damage in the pons and midbrain.

Sx:

Acute: Confusion, dizziness, memory loss (event amnesia), loss of consciousness, headache, tinnitus, nausea, vomiting, blurred vision.

Postconcussion: Headache, nausea, memory loss, irritability and personality changes, difficulty sleeping, fatigue, poor school performance, and inattentiveness.

Si:

Mental status changes including; confusion, long- and short-term memory loss, loss of consciousness.
Poor motor coordination, poor balance, or vertigo common.
Cranial nerve evaluation may show deficits with intracranial hemorrhage.

Concussion Grading: There are several grading systems that have been published. These differ substantially in both determination of severity and restriction in return to play. It would seem appropriate to use the more conservative (Colorado Medical Society) for collision sports where the risk of repeat injury is high, and the less restrictive (Cantu) for sports where the risk of re-injury is less.

Table 15.1 Concussion Grading

	Grade 1	Grade 2	Grade 3
Colorado Medical Society (CMS)	No loss of consciousness, with symptoms lasting less than 15 min	No loss of consciousness, with symptoms lasting more than 15 min	Any loss of consciousness
Cantu	No loss of consciousness; posttraumatic amnesia less than 30 min	Loss of consciousness less than 5 min or posttraumatic amnesia greater than 30 min	Loss of consciousness greater than 5 min or posttraumatic amnesia greater than 24 hr