Sports Medicine: Just the Facts

(Table 34-1). While academically accurate, the

provider on site is better served by a decision analysis

tool that quickly distinguishes between those headaches

that require minimal medical involvement and those that

might require rapid evaluation and treatment.

• Serious headache:Requires immediate evaluation and
  treatment. Occurs with or without trauma and is associ-
  ated with other neurologic symptoms to include mental
  status changes, nausea, vomiting, increased neck stiff-
  ness, or focal neurologic findings on examination.


• Concerning headache:Requires evaluation and treat-
  ment but not immediately. Patient meets criteria for
  concussion (confusion, amnesia, incoordination,
  slurred speech, emotional lability, or delayed motor or
  verbal response) but has none of the serious headache
  signs orsymptoms.


• Benign headache:No further evaluation or treatment
  required. Best described as a tension-type headache
  that occurs as a result of exertion or effort. Should only
  be used as a diagnosis of exclusion once an evaluation
  has ruled out both concerning and serious headaches.


• Clues to the correct diagnosis and effective treatment of
  an athlete with headache lie in a detailed history. Four
  key aspects of any headache include the following:
  
  
  1. Precipitating factors
  
  
  2. Character of headache pain
  
  
  3. Location of headache
  
  
  4. Preceding and accompanying symptoms
  
  
  
  


• These factors allow the clinician to properly catego-
  rize the patient with headache symptoms, thereby
  ensuring the appropriate and timely diagnostic testing
  and treatment.


• One small study of benign exertional headache found
  organic brain lesions as the headache source in nearly
  10% of its patients (Rooke, 1968).


• Benign exertional headache is typically precipitated
  by even minimal physical activity and is best

described as dull and throbbing in nature and can be

located unilaterally, bilaterally, or occipitally and may

last for several hours.

•Effort migraine is a vascular headache brought on by

extremely intense exercise. It is commonly unilateral

and throbbing in nature and is generally preceded by

scotomata or visual aura as seen in other forms of

migraine headaches.

•Weightlifter’s headache is typically a posterior

headache occurring in athletes straining to lift heavy

weights. Symptoms may last for days to weeks and

resolve relatively slowly when compared to other

benign headaches. Of note, several forms of underly-

ing pathology can present as a strain type headache

including Arnold Chiari malformations.

•Trauma-induced migraine is seen in athletes competing

in contact sports and is typically preceded by minor

head trauma without loss of consciousness followed

within minutes by visual, motor, and sensory aura

including scotomata, paresthesias, and even hemiplegic

symptoms. The headache is usually unilateral, throb-

bing, and retro-orbital. It may be accompanied by pho-

tophobia, nausea, and vomiting and may last for hours

to days in duration.

TREATMENT

•Treatment of benign exertional headaches includes

the use of nonsteroidal anti-inflammatory medications

either acutely or prophylactically (see Table 34-2).

•For athletes with effort migraine whose symptoms

resolve abruptly, treatment is not indicated. For those

athletes with prolonged debilitating symptoms, the

use of classic migraine medications may allow for a

faster return to activities (see Table 34-2). Instead of

prophylactic medications, symptoms can be prevented

by the use of longer warm-up periods.

•While treatment for weightlifter’s headache may

include rest, ice, and nonsteroidal anti-inflammato-

ries, recurrent strain type headaches warrant further

neurologic evaluation to include computed tomography

(CT) and/or Magnetic resonance imaging (MRI) to rule

out any underlying pathology as the headache source.

• Although the initial trauma-induced migraine must
  be fully evaluated via complete neurologic evalua-
  tion including neuroimaging studies because of its
  confounding presentation, subsequent similar
  headaches can be treated as classic migraines
  including the use of acute migraine medications.
  Prophylactic migraine medications are generally not
  recommended because of the unpredictable timing
  of these headaches.

TABLE 34-1 International Headache Society Classification
of Headache

1. Migraine


2. Tension-type headache


3. Cluster headache and chronic paroxysmal hemicrania


4. Miscellaneous headaches unassociated with structural lesion


5. Headache associated with head trauma


6. Headache associated with vascular disorders


7. Headache associated with nonvascular intracranial disorder


8. Headache associated with substances or their withdrawal


9. Headache associated with noncephalic infection


10. Headache associated with metabolic disorder


11. Headache or facial pain associated with disorder of cranium, neck,
    eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial
    structures


12. Cranial neuralgias, nerve trunk pain, and deafferentation pain


13. Headache not classifiable

200 SECTION 3 • MEDICAL PROBLEMS IN THE ATHLETE