Ask the Experts - What Is the Likely Etiology of Sudden Onset...
Ask the Experts - What Is the Likely Etiology of Sudden Onset...
What would be the most likely etiology of sudden onset exertional headaches in a 47-year-old patient who underwent aortic valve replacement (Carbomedics S500 valve) 4 months ago and in whom bleeding and aneurysm have been ruled out by MRA and CT?
Michael Gladson, MD
I have several questions about this case. What activities bring on the exertional headaches? Are they bilateral or unilateral, are there associated symptoms, and what is the duration? Does the patient have a history of migraine? The testing has excluded secondary causes of exertional headache with 1 rare exception. Cardiac ischemia can, rarely, cause a unilateral or bilateral headache brought on by exercise and relieved by rest. This kind of headache can occur alone or be accompanied by chest pain.
Benign exertional headache is brought on by physical activity and usually lasts from 5 minutes to 24 hours. The lifetime prevalence is 1% in the general population. It can be bilateral or unilateral, throbbing at onset, and may develop migrainous features in patients susceptible to migraine. Reported precipitants include running, rowing, tennis, and swimming. One particular activity may trigger headaches, whereas another does not. (I have a 36-year-old patient who developed exertional headaches when she started swimming lessons as training for a triathlon. Running, biking, and weight lifting did not trigger her headaches.) The headache can be prevented by avoiding excessive exertion, particularly in hot weather, high humidity, or at high altitude. A warm-up period may also prevent the headache in some people. Preventive medications that may be beneficial include indomethacin and beta-blockers. The headaches often go away with or without treatment.
There are other benign activity-related headaches. Cough headache includes headaches brought on by coughing, sneezing, weight lifting, bending, stooping, or straining with a bowel movement. This type of headache typically lasts less than 1 minute. Secondary causes to be excluded include posterior fossa tumors, Chiari malformation, platybasia, and basilar impression. Benign coital headaches have an explosive onset just before or during orgasm. Forty percent of those with this explosive type of sexual headache also have exertional headache. Caution is necessary when diagnosing the first sex headache because sexual activity is the precipitant of up to 12% of ruptured saccular aneurysms and up to 4% of bleeding arteriovenous malformations.
What would be the most likely etiology of sudden onset exertional headaches in a 47-year-old patient who underwent aortic valve replacement (Carbomedics S500 valve) 4 months ago and in whom bleeding and aneurysm have been ruled out by MRA and CT?
Michael Gladson, MD
I have several questions about this case. What activities bring on the exertional headaches? Are they bilateral or unilateral, are there associated symptoms, and what is the duration? Does the patient have a history of migraine? The testing has excluded secondary causes of exertional headache with 1 rare exception. Cardiac ischemia can, rarely, cause a unilateral or bilateral headache brought on by exercise and relieved by rest. This kind of headache can occur alone or be accompanied by chest pain.
Benign exertional headache is brought on by physical activity and usually lasts from 5 minutes to 24 hours. The lifetime prevalence is 1% in the general population. It can be bilateral or unilateral, throbbing at onset, and may develop migrainous features in patients susceptible to migraine. Reported precipitants include running, rowing, tennis, and swimming. One particular activity may trigger headaches, whereas another does not. (I have a 36-year-old patient who developed exertional headaches when she started swimming lessons as training for a triathlon. Running, biking, and weight lifting did not trigger her headaches.) The headache can be prevented by avoiding excessive exertion, particularly in hot weather, high humidity, or at high altitude. A warm-up period may also prevent the headache in some people. Preventive medications that may be beneficial include indomethacin and beta-blockers. The headaches often go away with or without treatment.
There are other benign activity-related headaches. Cough headache includes headaches brought on by coughing, sneezing, weight lifting, bending, stooping, or straining with a bowel movement. This type of headache typically lasts less than 1 minute. Secondary causes to be excluded include posterior fossa tumors, Chiari malformation, platybasia, and basilar impression. Benign coital headaches have an explosive onset just before or during orgasm. Forty percent of those with this explosive type of sexual headache also have exertional headache. Caution is necessary when diagnosing the first sex headache because sexual activity is the precipitant of up to 12% of ruptured saccular aneurysms and up to 4% of bleeding arteriovenous malformations.