Is This Primary Exertional Headache?

Patient Presentation
A 20-year-old female came to clinic with a history of headache. She was performing leg presses with increased weight and had a sudden onset of throbbing bilateral headache. She continued to do the leg presses but the pain increased and she became more nauseous. She went home and slept for about 90 minutes and woke up tired but without the headache. This occurred a second time later in the week but she stopped her workout and the headache duration was only a few minutes and she did not have nausea. She denied any other problems including numbness, tingling, aura, vision changes, etc. Her mentation and balance were normal at all times. She denied any fainting or palpitations. She said that possibly she was dehydrated the first time but she had been specifically drinking more the second time and usually had 2 liters of fluid daily. She denied any drugs, medications, or disordered eating patterns.

The past medical history was positive for migraine. She had about 2-3 episodes per year that were usually associated with decreased sleep or dehydration. The family history was positive for an older uncle who had some type of vascular surgery. The review of systems was normal.

The pertinent physical exam showed a healthy appearing female with weight in the 25% and height at the 50%. Blood pressure was 102/66 and pulse was 70. Her physical examination was normal including her neurological examination.

The diagnosis of a sudden onset of headache associated with exertion was made. After reading about these types of headaches and the potential risk of vascular abnormalities and the unknown problem with the uncle, a pediatric neurologist was consulted who agreed with brain imaging. The radiologic evaluation of a brain magnetic resonance imaging was normal. The diagnosis of a primary exertional headache was made and the patient counseled regarding natural history and methods to decrease the possible recurrence.

Commonly occurring primary headaches include tension, cluster and migraine headaches. “Other primary headaches” are often situational. Patients can have more than 1 type of these “other” headaches along with more common headaches. Other primary headaches as a group tend to be self-limited with long remission periods. Some other primary headaches include:

  • Thunderclap headache
    • Explosive sudden onset with maximum intensity in less 1 minute and resolution within 5 minutes usually
    • 43/100,000 persons in adults
    • Primary or secondary
    • Secondary causes include intracranial hemorrhage, stroke, thromboembolism, hypertensive encephalopathy etc.
  • Cough headache
    • Associated with or brought on by cough or other Valsalva maneuvers and lasts < 48 hours
    • Valsalva maneuvers can include straining, bending over, laughing, sneezing etc.
    • Note that a migraine headache is different as it is worsened not precipitated by Valsalva
    • 1% lifetime prevalence
    • In pediatric population has been associated with Chiari I malformation but appears to have benign outcome for most patients
    • Treatment with indomethacin
  • Headache associated with sexual activity
    • Occurs during or brought on by sexual activity with either or both of: increased intensity with sexual excitement or explosive intensity around orgasm
    • Lasts 1 minute to 72 hours
    • Treatment with indomethacin or beta blockers
  • Other types include cardiac, cold stimulus, external pressure, hypnic, or nummular headaches

Learning Point
Primary exercise headache (PEH) is a headache occurring during or immediately after exercise that has no known intercranial pathology

  • Occurs during or brought on by strenuous physical exercise (within 30 minutes) and lasts < 48 hours
  • Usually throbbing-type headache
  • About 1% of the general population
  • More common in young with average age of ~40 years with studies mixed on gender occurrence
  • Often co-morbid with migraine with aura (up to 50% have some type of co-morbid migraine)
  • Dysregulated cerebral vasculature is the presumed cause but is not well understood
  • Usually this is benign but differential diagnosis includes:
    • Cervical artery dissection
    • Chiari malformation
    • Idiopathic intracranial hypertension
    • Reversible cerebral vasoconstriction syndrome
    • Pheochromocytoma
    • Subarachnoid hemorrhage
    • Space occupying lesions
    • Cardiac cephalgia
  • Treatment includes avoidance of precipitating activity levels, increasing activities over a long time period (weeks to months), long warmups, ensuring headgear is not restrictive, avoiding hot weather, high altitude or dehydration.
    Medical treatment is with indomethacin or beta blockers.

Questions for Further Discussion
1. What are common treatments for headaches? A review can be found here
2. What are common recommendations for athletic injury prevention?
3. What are indications for imaging for headache?

Related Cases

    Disease: Primary Exertional Headache | Headache

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Headache

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Sandoe CH, Kingston W. Exercise Headache: a Review. Curr Neurol Neurosci Rep. 2018;18(6):28. doi:10.1007/s11910-018-0840-8

Upadhyaya P, Nandyala A, Ailani J. Primary Exercise Headache. Curr Neurol Neurosci Rep. 2020;20(5):9. doi:10.1007/s11910-020-01028-4

Bahra A. Other primary headaches – thunderclap-, cough-, exertional-, and sexual headache. J Neurol. 2020;267(5):1554-1566. doi:10.1007/s00415-020-09728-0

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa