Migraine After Training in Athletes: Causes and the Connection with Exertion and Pharmacology

Throbbing head pain, nausea and intolerance to light after intense training make many athletes think that sport is "contraindicated" for them. In reality, the connection between physical exertion and migraine is twofold: exertion can provoke attacks, but regular activity can reduce their frequency. Our editorial team explains what mechanisms are at work here and how supplements and medications affect the headache.

Migraine or Exertional Headache: What Is the Difference

The International Classification of Headache Disorders (ICHD-3, 2018) distinguishes several conditions that athletes often lump together under the word "migraine." Migraine itself is a primary neurological disease with recurring attacks of moderate or severe, often one-sided throbbing pain that worsens with physical activity and is accompanied by nausea, photophobia and phonophobia. In some people the attack is preceded by an aura — visual or other transient neurological symptoms.

Separately distinguished is primary headache associated with physical exertion (code 4.2 in ICHD-3). It occurs only during or after strenuous physical work, lasts less than 48 hours and is not explained by another cause. Such pain is especially characteristic of heat and altitude.

In people who already have migraine, exertion can provoke typical migraine attacks. In the study by Koppen and van Veldhoven (2013), a significant proportion of patients with migraine reported that exertion at least sometimes provoked an attack in them, and such people more often had a cervical localization of pain at the onset of the attack.

The most important distinction is between primary headaches and secondary ones, that is, symptoms of another illness. A sudden "thunderclap" pain during straining may be a sign of hemorrhage, and pain during exertion for the first time in life, especially in older people, requires examination. A separate editorial material is devoted to these "red flags."

How Training Triggers an Attack

The exact mechanism of migraine is still being studied, but a key role is attributed to the trigeminovascular system — the sensory fibers of the trigeminal nerve that innervate the membranes of the brain and their blood vessels. During an attack, neuropeptides are released, in particular CGRP, which cause vasodilation and neurogenic inflammation. It is at CGRP that the newest classes of antimigraine drugs are aimed.

Intense exertion changes several parameters at once: arterial pressure rises, cerebral blood flow changes, body temperature increases, glucose levels drop, fluid is lost. In a brain prone to migraine, any of these changes can become the impetus for an attack.

Suddenness plays an important role. An abrupt start without a warm-up, maximal sprints, strength exercises with breath-holding and straining (the Valsalva maneuver) produce a rapid increase in pressure and intracranial pressure. It is precisely such situations that are more often described by patients in whom training provokes pain.

The state "afterward" also matters. Some attacks develop not during training but several hours later: against the background of glycogen depletion, insufficient rehydration and an abrupt transition from high activity to rest.

Triggers Associated with an Athlete's Regimen

Migraine is sensitive to irregularity. Missed meals, a changed sleep schedule, flights across time zones, pre-start stress and the relaxation after it — all these are typical factors of an athlete's life that neurologists describe as triggers of attacks.

For contact sports one should also remember trauma: a headache after a blow to the head may be a symptom of a concussion, not a migraine. Such a situation is assessed by a doctor according to special protocols.

Strict diets deserve separate attention. A prolonged calorie deficit, ketogenic regimens at the initial stage, restriction of carbohydrates before competitions in weight categories — all this can provoke attacks in susceptible people.

Supplements and Pharmacology That Affect Headache

Caffeine has a dual role. In small amounts it is part of some painkillers and can enhance their effect. However, regular consumption of large doses creates dependence, and its withdrawal causes a headache that ICHD-3 singles out as a separate diagnosis. Athletes who drink a lot of coffee and pre-workout formulas and then abruptly stop often encounter precisely this.

Supplements that increase the production of nitric oxide (L-arginine, L-citrulline, nitrates from beets) are popular for the "pump" and endurance. It is known that NO donors, for example nitroglycerin, are a classic experimental model for provoking a migraine attack. There are few direct studies on sports supplements, but people with migraine should carefully monitor their reaction to such products.

• Stimulants(synephrine, yohimbine, DMAA and the like): raise pressure and can provoke pain.
• Anabolic steroids and other hormonal drugs:an increase in pressure and hematocrit is described as a possible cause of headache.
• Monosodium glutamate, alcohol, especially red wine:frequently mentioned dietary triggers.
• Painkillers:frequent use can cause medication-overuse headache.

Medication-overuse headache is one of the most important problems. If a person takes simple painkillers 15 or more days a month, or triptans and combination drugs 10 or more days a month, the headache can become more frequent precisely because of the medications. Athletes who regularly take NSAIDs for muscle and joint pain are in the risk zone.

A separate nuance is anti-doping rules. Beta-blockers, which are used for the prevention of migraine, are banned by WADA in certain sports, in particular in shooting and archery. Diuretics, which sometimes are part of the treatment of accompanying conditions, are banned in all sports. Therefore, the prescription of preventive therapy to an athlete must necessarily take into account the Prohibited List and, if needed, the therapeutic use exemption procedure.

Exercise as Part of Prevention

Paradoxically, regular aerobic activity is regarded as one of the non-pharmacological methods of migraine prevention. In the randomized study by Varkey and colleagues (2011), aerobic training three times a week for three months reduced the frequency of attacks about as much as relaxation techniques or the drug topiramate.

Possible mechanisms are improved pain regulation, an effect on endogenous opioids and endocannabinoids, reduced stress, and the normalization of sleep and body weight. The systematic review by Amin and colleagues (2018) summarizes that physical activity has potential as a preventive agent, although the evidence base is still limited.

The key is in dosing the exertion. Gradual progress, thorough warm-up, avoidance of abrupt sprints and straining at the start, adequate hydration and carbohydrates before and after training allow most people with migraine to train without provoking attacks.

Training during an attack, on the contrary, is undesirable: the pain intensifies from activity, while nausea and visual disturbances make the session dangerous. It is better to return to training after the attack has completely passed.

Editorial Conclusions

A headache after training can be either a migraine attack provoked by exertion, or a separate primary exertional headache — and sometimes a symptom of a serious illness.

The most frequent triggers in athletes are dehydration, low glucose, an abrupt start, sleep disturbances and stress. Among pharmacological factors, caffeine (especially its withdrawal), NO donors, stimulants, hormonal drugs and the overuse of painkillers are important.

Regular, properly dosed aerobic activity, on the contrary, can reduce the frequency of attacks.

We also recommend reading our materials about the prevention and diagnosis of migraine after training, about caffeine in sport and about muscle cramps in athletes.

References

1. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211.
2. Koppen H, van Veldhoven PLJ. Migraineurs with exercise-triggered attacks have a distinct migraine. J Headache Pain. 2013;14:99.
3. Varkey E, Cider A, Carlsson J, Linde M. Exercise as migraine prophylaxis: a randomized study using relaxation and topiramate as controls. Cephalalgia. 2011;31(14):1428–1438.
4. Amin FM, Aristeidou S, Baraldi C, et al. The association between migraine and physical exercise. J Headache Pain. 2018;19(1):83.
5. Ashina M. Migraine. N Engl J Med. 2020;383(19):1866–1876.
6. Diener HC, Dodick D, Evers S, et al. Pathophysiology, prevention, and treatment of medication overuse headache. Lancet Neurol. 2019;18(9):891–902.
7. World Anti-Doping Agency. The World Anti-Doping Code: International Standard. Prohibited List. Montreal: WADA; чинна редакція.