What is the treatment for headaches when descending from high elevation?

Treatment for Headaches When Descending from High Elevation

For headaches occurring during descent from high elevation, NSAIDs like ibuprofen are the first-line treatment due to their proven efficacy and safety profile. 1 These medications not only relieve pain but also address the underlying inflammatory processes that may contribute to altitude-related headaches.

Pathophysiology of Descent Headaches

Headaches during descent from high altitude are primarily related to:

• Pressure changes affecting the sinuses and trigeminal nerve endings
• Barotrauma to the ethmoidal sinuses
• Cerebral vasodilation that occurs during pressure changes
• Possible residual effects of high altitude exposure

Treatment Algorithm

First-Line Treatments:

1. NSAIDs

   • Ibuprofen: Most studied for altitude headaches with significant superiority over placebo 1
   • Other options: Diclofenac, naproxen, or indomethacin (may have additional benefit of reducing intracranial pressure) 2
   • Dosing: Standard analgesic dosing (e.g., ibuprofen 400-600mg)
   • Timing: Take at first sign of headache during descent

2. Simple Analgesics

   • Paracetamol/acetaminophen: Alternative for those who cannot tolerate NSAIDs 2
   • Less effective than NSAIDs but still beneficial

Physical Maneuvers (Adjunctive):

Several non-pharmacological techniques can provide relief:

• Compression of the pain region
• Valsalva maneuver
• Extension of the earlobe
• Chewing and yawning 2

Second-Line Treatments:

For severe or persistent headaches:

• Triptans: May be effective for severe headaches with migrainous features 2
• Avoid opioids: Not recommended for headache management 2

Special Considerations

For Those with History of Altitude Headaches:

Prophylactic measures may be considered:

• Pre-treatment with NSAIDs before beginning descent
• For those with recurrent severe symptoms, consider acetazolamide which can help with altitude adaptation 2

For Women:

Women may experience higher risk of altitude-related headaches:

• Consider screening for acute mountain sickness using Lake Louise Scoring system
• May benefit from slower descent rates (<400 m/day) 2

Pitfalls and Caveats

1. Medication overuse risk: Limit analgesic use to avoid medication overuse headache (no more than 15 days/month for simple analgesics or 10 days/month for combination medications) 2

2. Differential diagnosis: Ensure the headache is truly related to descent and not a manifestation of:

   • High altitude cerebral edema (HACE) - requires immediate descent and oxygen
   • Migraine triggered by altitude changes
   • Sinus barotrauma

3. Hydration status: Dehydration can worsen altitude headaches, so maintaining adequate hydration during descent is crucial

4. Timing of medication: Most effective when taken early in the headache development rather than waiting until severe pain develops

By following this approach, most individuals experiencing headaches during descent from high elevation can achieve effective relief. The evidence strongly supports NSAIDs as the most effective and safest option for these specific headaches.