What Is Exertion Headache?
Exertion headaches occur during or after strenuous physical activity and other activities that increase abdominal pressure. These include sports, arduous work, sneezing, or sexual intercourse [1,2].
All exertion headaches, or exercise headaches, as they are commonly called, will present around the time of activity with throbbing or pulsating pain and discomfort across both halves of the head, sometimes the most severe at the back of the head.
Treatment options vary depending on whether your headache is due to exertion alone or is triggered by exertion due to a more serious underlying cause. Some exertion headaches resolve or stop entirely, or may be alleviated by daily over-the-counter pain medication and other options.
If you believe you are experiencing an exertion headache, or any severe headache, you should consult your physician. He or she can determine the cause and recommend the best course for treatment.
Exertion Headache Symptoms
Pain may improve within several minutes or may persist for several days. Primary exercise headaches usually improve within 48 hours.
Regardless, all exercise headaches tend to have the following characteristics:
- Timing: They occur during or after strenuous exercise.
- Pain: They consist of throbbing pain or pain that pulsates rhythmically in the head.
- Discomfort: This is felt across both halves of the head, sometimes most severe in the back of the head (occiput).
You may find that your exercise headaches morph into migraines and have features such as:
More serious symptoms
In addition, secondary exercise headaches may include “red flag” symptoms such as:
Exertion Headache Causes
Common activities that can trigger exertion headaches include sports such as weightlifting, running, aerobics, tennis, swimming, and rowing, as well as singing, coughing or sneezing, straining on the toilet, and sexual intercourse. Exertion headaches can be categorized into two groups, primary and secondary, which causes vary.
Primary exertion headaches
These are most common, in which the headache occurs despite the absence of any identifiable structural problem in the brain . Primary exertion headaches are usually harmless, and it should be noted that they are different from migraines brought on by exertion . They can be relieved with mild medications and typically do not require serious medical interventions. The exact cause of primary exertion headaches is not well understood. Possible explanations include:
- Vasodilation: Blood vessels in the skull become wider (dilate) with exercise, which may increase pressure inside the skull and lead to pain.
- Cerebrospinal fluid levels: Abnormalities in the volume or flow of this fluid may be a cause.
- Compression of blood vessels: This occurs with muscle tension.
- Neck muscle tension or strain
- Stimulating certain neurotransmitters in the brain
- Raised abdominal pressure
Secondary exertion headaches
These headaches are caused by a significant underlying structural problem in the brain and may be related to a problematic accumulation of materials or diseased arteries, for example. They can be life-threatening and may require emergency medical attention. Possible causes — although some are rare — may include:
- Bony abnormalities: These may be of the skull, neck, or spine, such as Chiari malformation .
- Disruption in the flow of cerebrospinal fluid (CSF): This is the liquid that surrounds the brain and spinal cord leading to CSF pooling (hydrocephalus).
- Space-occupying masses in the brain: This can be due to cancer (tumors), infections (abscesses), or accumulations of blood (hematoma).
- Bleeding on the surface of the brain: Even small amounts of bleeding between the brain and its surrounding membranes (subarachnoid hemorrhage) can be excruciatingly painful.
Who is most likely to be affected
Exercise headaches occur most frequently in people who :
- Exercise in hot and humid environments
- Exercise at high altitudes
- Are around 40 years old 
- Have a personal or family history of migraine headaches
- Have a history of head trauma, such as previous concussions
- Have a history of cancer or HIV
Exertion Headache Symptom Checker
Take a quiz to find out if you have Exertion Headache
Treatment Options, Relief, and Prevention for Exertion Headache
Treatments vary depending on whether your exertion headaches are due to primary or secondary causes. If you experience symptoms that are concerning to you, or you have any reason to believe you may have a brain tumor or bleeding in your brain, consult your physician.
If you experience frequent exercise headaches, your physician may recommend medications to prevent headaches, such as naproxen (Aleve) or other over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs). A stronger prescription NSAID, indomethacin, may be prescribed for exertion headaches.
Other treatments if first-line medications are not enough:
- Beta blockers: Blood pressure medications such as propranolol (Inderal) and metoprolol can also prevent exercise headaches.
- Ergonovine: This medication is also sometimes used for migraines that affect the contraction of blood vessels in the brain.
- Triptans: These are medications for migraines that act on the serotonin neurotransmitter and can also sometimes be effective for exertion headaches.
- Melatonin: This is a hormonal food supplement that is often used for sleep and may also help relieve exertion headaches .
Treatment for secondary causes
If your exertion headaches are the result of bony abnormalities, improper flow of cerebrospinal fluid, a brain tumor, bleeding, or other significant structural abnormalities, procedures may be necessary in order to prevent more serious complications.
A few different adjustments can be made to your exercise regimen and daily routine to limit the occurrence of exertion headaches.
- Activity modification: Avoid activities that seem to lead to the most severe headaches.
- Avoid exercising in hot and humid weather: On hot days, consider exercising indoors or in the evening or early morning when the heat is less intense.
- Minimize exercise at high altitudes
- Warm up: You should do so prior to intense activity but remember to not push yourself too hard.
- Stay hydrated: You should drink water throughout the day and especially before exercising.
- Exercise steadily: You should escalate physical activity at a slow rate and avoid extreme exercise.
- Avoid aggravating substances: This includes those that can exacerbate headaches, such as alcohol, anabolic steroids, and nicotine.
Primary exertion headaches can have a self-limited course, subsiding significantly within six months, or can persist for years. The prognosis for secondary exertion headaches depends on the underlying cause.
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When to Seek Further Consultation for Exertion Headache
If you experience a headache that includes vomiting, loss of consciousness, or neck stiffness, seek medical attention immediately. These could be signs of a serious problem that requires prompt evaluation and treatment. Your medical evaluation may include a physical neurological examination, imaging of the brain (either CT or MRI), and possibly blood work or a spinal tap (lumbar puncture).
If you suddenly experience the worst headache of your life
If your headache starts suddenly (sometimes described as a “thunderclap”) and feels different from and/or worse than any other headaches you have previously experienced, then it is important to seek emergency medical attention. This could be a sign of a serious problem that requires urgent attention.
If you have a headache that does not improve
If your headache gets worse day after day or does not improve within a few hours, it is important to seek medical attention to evaluate for a more serious condition.
If you have headaches on repeated occasions
If you continue having headaches during multiple episodes of exertion, it is advisable to seek medical attention to evaluate for any secondary causes of headache and discuss treatment options.
If you have a headache with systemic symptoms, such as fever, weight loss, or fatigue
If your headache co-occurs with body-wide symptoms, such as fever or you have experienced unintentional weight loss, seek medical attention for a full evaluation. These could be signs of a more serious illness.
- Exertional headaches. National Headache Foundation. National Headache Foundation Link
- Exercise headaches. Mayo Clinic. Published April 26, 2018. Mayo Clinic Link
- Williams SJ, Nukada H. Sport and exercise headache: Part 2. Diagnosis and classification. Br J Sports Med. 1994;28(2):96-100. NCBI Link
- Primary exercise headache. American Migraine Foundation. American Migraine Foundation Link
- Pascual J, Gonzalez-Mandly A, Oterino A, Martin R. Primary cough headache, primary exertional headache, and primary headache associated with sexual activity. Handb Clin Neurol. 2010;97:459-468. PubMed Link
- Primary exertion headache. Johns Hopkins Medicine. Johns Hopkins Medicine Link
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