Exercise headache is a headache syndrome defined by the International Headache Society as “primary exercise headache.” The most distinctive feature of this headache type is that it is triggered only by physical activity and generally disappears spontaneously when activity is terminated.

What is Exercise Headache?

Exercise headache is a primary headache type that occurs directly related to physical activity. This pain type can start during exercise or immediately after. Exercise headache is mostly:

• Felt as throbbing or pressure-type,
• Shows bilateral spread,
• Can be moderate or severe in intensity,
• Appears shortly after exercise starts and decreases with rest.

Exercise headache is distinguished from other headache types by being triggered only by physical activity and generally passing spontaneously when activity is terminated. It is most commonly seen during endurance-requiring sports (for example, running, swimming, cycling, weightlifting). Therefore, it can be a more prominent problem especially in professional or intensively training athletes. Exercise headache, which can seriously affect physical performance, can negatively affect athletic performance as well as reduce exercise motivation.

What Causes Exercise Pain?

Many different mechanisms play a role in the occurrence of exercise headache. Physiological changes occurring in the body during physical activity, the vascular structure of the brain, and the musculoskeletal system contribute to this process.

1. Blood Pressure and Vascular Dilation

During exercise, the heart beats faster and arterial blood pressure suddenly rises. This elevation can lead to dilation and contraction of brain vessels. Sudden vascular changes are felt as pressure sensation in the head or throbbing pain.

2. Changes in Brain Pressure

During intense effort, there are fluctuations in intracranial pressure. This situation is more prominent especially in endurance-requiring sports and can be a fundamental mechanism in the onset of headache.

3. Metabolic Factors

Exercise headache is not only related to vessels.

• Fluid loss (dehydration)
• Electrolyte imbalance (especially sodium and potassium loss)
• Blood sugar drop (hypoglycemia)
  such conditions can also trigger pain. This risk increases especially in people doing long-duration sports in hot weather.

4. Muscle and Spine-Related Factors

Excessive tension in neck and shoulder muscles is a commonly seen situation during exercise. Intense contraction of these muscles:

• Can create pressure on cervical vertebrae,
• Can facilitate headache by affecting nerves and vessels.

5. Changes in Brain Chemistry

Sudden fluctuations in serotonin and other neurotransmitters occur during exercise. Although endorphins that normally make you “feel good” after exercise are secreted, sometimes these rapid chemical changes can trigger headache.

International Classification of Headache Disorders (ICHD-3) Diagnostic Criteria- 4.2 Primary Exercise Headache

According to the ICHD-3 (International Classification of Headache Disorders-3) classification prepared by the International Headache Society (IHS), primary exercise headache is defined with the following criteria:

1. Headache must occur in at least 2 attacks.
2. Pain must start only during or immediately after physical exertion.
3. Pain characteristics:
   • Can last between minutes and 48 hours.
   • Generally pulsatile (throbbing) in character.
   • Tends to be bilateral.
4. Cannot be explained by another disease.
   • For example, secondary causes such as cerebral vascular occlusion, brain tumor, subarachnoid hemorrhage must be excluded.

What are the Symptoms of Exercise Headache?

The symptoms of exercise headache are generally quite distinctive and can be easily distinguished when correctly described.

Main Characteristics

• Onset time: Pain mostly appears a few minutes after exercise starts or begins shortly after activity ends.
• Type of pain: Felt as throbbing, pulsatile.
• Location: Mostly felt on both sides of the head; especially concentrates in the temple (temporal) and forehead (frontal) regions.
• Severity: Can start at moderate level and become severe, can be unbearable in some cases.

Accompanying Symptoms

Exercise headache can be accompanied not only by pain but also by other complaints:

• Neck and nape stiffness,
• Mild nausea,
• Sensitivity to light (photophobia),
• Rarely dizziness.

Duration of Pain

• Pain can generally last between 5 minutes and 48 hours.
• Pain can intensify as exercise duration and intensity increase.

Conditions That Increase Pain

Some conditions can lead to more intense feeling of exercise headache:

• Hot weather and humid environments,
• Doing sports at high altitude,
• Not taking adequate fluids (dehydration),
• Long-duration or endurance-requiring sports.

Can Exercise Headache Be Confused with Migraine?

Exercise headache and migraine can sometimes show similar characteristics to each other. However, it is possible to distinguish them carefully:

Similarities

• Both can be throbbing in nature.
• Light sensitivity and nausea can be seen in both.

Differences

• Onset: Migraine generally starts spontaneously; exercise headache appears only during or immediately after physical exertion.
• Duration: While exercise headache varies between 5 minutes – 48 hours, migraine generally can last 4–72 hours.
• Location: Migraine is frequently unilateral; exercise headache is mostly bilateral.
• Accompanying Symptoms: Visual aura, vomiting, or smell sensitivity specific to migraine can be more pronounced.

When Should You Consult with a Neurology Specialist?

There are situations where individuals experiencing exercise headache should consult with a neurology specialist.

Situations Requiring Attention

• First-time occurring headache: If a headache never experienced before develops during exercise, it must be evaluated.
• Very severe headache: Sudden and severe pains described as “the worst headache of my life” may require emergency intervention.
• Pains becoming increasingly frequent or intensifying: Pains that were mild at the beginning increasing over time.
• Newly starting exercise headache over age 40: Excluding secondary causes is especially important in this age group.

Accompanying Alarm Symptoms

If any of the following symptoms accompany exercise headache, a doctor should be consulted urgently:

• Fever, neck stiffness,
• Blurred vision or double vision,
• Speech disorder, confusion,
• Weakness, numbness in arms or legs,
• Loss of balance or severe dizziness.

Daily Life Impact

If headache is reducing your desire to do sports, lowering your performance, or seriously impairing your quality of life, it is necessary to get expert opinion.

How is Exercise Headache Diagnosed?

The diagnosis of exercise headache is primarily made through detailed history (anamnesis) and clinical evaluation. The doctor carefully queries the pain’s relationship with exercise, when it started, its duration, severity, and other accompanying symptoms.

1. Clinical Evaluation

• Pain appearing only during or immediately after exercise,
• Passing within a certain time after exercise stops,
• This condition showing a repetitive pattern,
  are the most important clues for diagnosis.

2. Neurological Examination

• Detailed neurological examination is very important in terms of excluding possible secondary causes.
• In exercise headache, there is generally no lateralizing neurological finding

3. Imaging and Tests

In some cases, additional tests may be used to clarify diagnosis and exclude serious diseases:

• Brain MRI or CT angiography: To exclude presence of occlusion, dilation, or malformation in brain vessels,
• Lumbar puncture: Rarely, in case of suspicion of infection or bleeding in cerebrospinal fluid,
• Blood tests: In differential diagnosis of dehydration, electrolyte imbalance, or metabolic problems.

In most exercise headache patients, these tests come out normal, but especially if there are red flag symptoms (sudden and very severe headache, vision impairment, confusion, etc.), they must be performed.

4. Differential Diagnosis

To distinguish exercise headache, the following conditions should also be considered:

• Exercise-induced migraine,
• Hypertensive crisis,
• Dehydration or heat-related headache,
• Cerebral vascular malformations (e.g., aneurysm, AVM).

Who Gets Exercise Headache?

Exercise headache can be seen in every age group in society. While its rate in the general population is approximately 1–2%, in those who exercise regularly this rate can rise up to 10–15%. It is encountered more frequently especially in athletes doing intensive training.

Age Distribution

• Most frequently seen in the 20–40 age range.
• More prominent in youth and young adults, especially after newly started intensive exercise programs.

Gender

• Although seen slightly more frequently in males, it can appear in both genders.

Groups Where It Is More Common

• Those doing endurance sports: Runners, cyclists, swimmers.
• Those doing sports at high altitude or exposed to sudden altitude changes.
• Those exercising in hot and humid climates.
• Beginner athletes: Can frequently appear after intense activity especially in individuals with low conditioning.

Risk Factors

There are some conditions that increase predisposition to exercise headache:

• History of migraine or other headaches,
• Those with family history of headache,
• People prone to dehydration,
• Irregular eating habits,
• Stressful life events

How Is Exercise Headache Treated?

Treatment of exercise headache is addressed under two main headings:

1. Acute treatment (relief during attack)
2. Preventive strategies (reducing recurrence of attacks)

1. Acute Treatment Approaches

• Painkillers: Non-steroidal anti-inflammatory drugs (NSAIDs) – ibuprofen, naproxen, or paracetamol can be used. Regular and uncontrolled use should be avoided.
• Cold application: Cold compress can be applied to forehead and temples for 15–20 minutes.
• Rest: Short-term rest in a cool, dark, and quiet environment can alleviate pain.

2. Preventive Treatment Strategies

Lifestyle Changes

• Drinking plenty of water: Regular fluid should be taken before, during, and after exercise.
• Eating pattern: A light and balanced meal should be consumed 2–3 hours before exercise. Intense exercise on an empty stomach should be avoided.
• Sleep: Regular sleep habits should be established.

Exercise Adjustments

• Gradual increase: Exercise intensity should not be suddenly increased.
• Warm-up and cool-down: At least 10–15 minutes of warm-up and cool-down movements at the end should be performed.
• Correct form: Excessive load should not be placed on neck and shoulder muscles.

Medication Prevention (prophylaxis)

• In frequently recurring and severe exercise headaches, medications such as propranolol, indomethacin, or topiramate can be used under doctor control.

Physical Therapy and Exercise Modifications

• Exercises strengthening neck and shoulder muscles,
• Posture-correcting movements,
• Personalized programs with physical therapy specialist can reduce pain frequency.

Frequently Asked Questions About Exercise Headache

1. Why does exercise headache occur?

Blood pressure fluctuations, fluid loss, low blood sugar, muscle tension, and inadequate warm-up are the main causes.

2. How can I prevent exercise headache?

• Take plenty of fluids before exercise.
• Consume a light and balanced meal.
• Don’t neglect warm-up and cool-down.
• Increase exercise intensity gradually.

3. How long does it last?

Can last between 5 minutes and 48 hours. While mild cases pass quickly, in some situations it can continue for one–two days.

4. Is it dangerous? When should I see a doctor?

In most cases, it is harmless. However, first-time occurring, very severe, suddenly starting pains (“worst headache of my life”) require emergency evaluation. Also, if neurological findings such as vision loss, speech difficulty, muscle weakness accompany, a doctor should be consulted without delay.

5. Which exercises trigger it more?

• Risky activities: Marathon, long-distance cycling, heavy weightlifting, HIIT training, sports at high altitude.
• Safer options: Swimming, paced walking, yoga, pilates, light weight work.

It should not be forgotten that these questions and answers are for general informational purposes. Exercise headache is mostly benign and can be controlled with correct methods. However, if it recurs frequently or is severe, it must be evaluated by a neurology specialist.