What is the recommended treatment for a new exertion headache?

New Exertion Headache: Recommended Treatment

For a new exertion headache, you must first rule out subarachnoid hemorrhage (SAH) and other life-threatening secondary causes with urgent neuroimaging before considering treatment for primary exertional headache. 1

Immediate Diagnostic Workup (Priority #1)

A new exertion headache is a red flag requiring urgent evaluation because:

• Onset during exertion is one of the Ottawa SAH Rule criteria that mandates additional investigation for subarachnoid hemorrhage 1
• Exertional headache can be the presenting symptom of SAH, sentinel bleed, or cardiac ischemia 1, 2
• Approximately 10% of exertional headaches have an organic (secondary) cause 3

Required Initial Evaluation:

• Non-contrast head CT within 6 hours of onset (98.7% sensitive for SAH when performed within this window) 1
• If CT is negative or non-diagnostic and clinical suspicion remains high: lumbar puncture for xanthochromia (performed >6 hours after symptom onset, with 100% sensitivity and 95.2% specificity) 1
• Consider CT angiography to evaluate for vascular pathology if initial workup is inconclusive 1
• Thorough neurologic examination looking for focal deficits, meningismus, or altered consciousness 1

Additional Red Flags to Assess:

• Age ≥40 years at onset 1, 4
• Neck pain or stiffness 1
• Witnessed loss of consciousness 1
• Thunderclap quality (instantly peaking pain) 1
• Prolonged duration (>minutes to hours) 4
• New neurological deficits 1

Treatment for Primary Exertional Headache (After Secondary Causes Excluded)

Once dangerous secondary causes are ruled out, primary exertional headache (PEH) is generally benign and self-limited 5, 4.

First-Line Treatment Approach:

1. Trigger Avoidance and Lifestyle Modifications:

• Proper warm-up before exercise 3
• Adequate hydration and nutrition 3
• Good sleep hygiene 3
• Minimization of environmental risks (heat, altitude) 3

2. Pharmacologic Prophylaxis (if trigger avoidance insufficient):

• Indomethacin is the most effective prophylactic medication for primary exertional headache 5, 6
• Alternative: Beta-blockers may be effective for patients who cannot tolerate NSAIDs 4
• Short-term prophylactic NSAIDs taken 30-60 minutes before anticipated exertion 4, 6

Treatment Duration and Prognosis:

• Primary exertional headache is typically self-limited, often resolving spontaneously over weeks to months 5
• Prophylactic treatment can be discontinued after several weeks to months if headaches resolve 6
• Reassess if headaches persist, worsen, or change character, as this may indicate a secondary cause 4

Common Pitfalls to Avoid:

• Never assume a new exertional headache is benign without proper imaging - missing SAH carries catastrophic consequences with 4-fold higher mortality if diagnosis is delayed 1
• Don't rely solely on "classic" SAH presentation - 12% of SAH cases are initially misdiagnosed, and exertional onset may be the only clue 1
• Consider cardiac ischemia in older patients with exertional headache, particularly if unilateral - this can be an atypical anginal equivalent 2
• Don't confuse primary exertional headache with migraine triggered by exercise - PEH is brief (seconds to minutes) and begins immediately with exertion, while exercise-induced migraine has typical migraine features and longer duration 6, 3
• Avoid chronic NSAID overuse, which can lead to medication-overuse headache 4