What causes headaches in a teenager during warm-up for sports and how can they be managed?

Headaches During Sports Warm-Up in Teenagers

Most headaches occurring during warm-up in teenagers are benign primary exercise headaches that respond to proper warm-up techniques, adequate hydration, and NSAIDs when needed, but you must first rule out concussion if there was any head trauma. 1, 2

Immediate Assessment: Rule Out Concussion First

If the teenager experienced any head impact before the headache started, immediately remove them from activity and evaluate for concussion, as headache is the most frequently reported concussion symptom. 3, 1

Red flags requiring emergency evaluation include:

• Loss of consciousness or altered mental status 1
• Repeated vomiting or severe/worsening headache 1
• Confusion, amnesia, or focal neurological deficits 3, 1
• Visual changes or balance problems 1

If concussion is suspected: Never allow same-day return to play, even if symptoms resolve, and implement complete physical and cognitive rest for 24-48 hours before beginning a gradual return-to-play protocol. 1, 4

Primary Exercise Headache (No Head Trauma)

When head trauma is excluded, these are typically benign primary exercise headaches triggered by physical exertion during warm-up. 2, 5

Key Diagnostic Features

Primary exercise headache characteristics:

• Triggered specifically by physical exertion or warm-up activities 2, 5
• Affects 1-26% of the adolescent/adult population 5
• Usually self-limited and benign 2, 5
• May be the sole trigger or one of multiple headache triggers 2

Important caveat: Approximately 10% of exercise-induced headaches have an organic (secondary) cause requiring thorough evaluation. 2

Management Approach

First-line non-pharmacologic interventions:

• Proper warm-up before exercise is the hallmark of treatment—ensure gradual, progressive warm-up rather than abrupt exertion 2
• Minimize environmental risks including heat and humidity exposure 3, 2
• Ensure proper sleep hygiene and adequate rest 2
• Maintain good nutrition and hydration status before, during, and after activity 3, 2

Pharmacologic management when needed:

• NSAIDs (short-term use) can be effective for primary exercise headache 2, 5
• Beta-blockers may be considered for recurrent cases 5
• Use only acetaminophen if concussion cannot be definitively ruled out 1

Heat-Related Considerations

Environmental factors significantly contribute to exercise headaches in teenagers:

• Hot and humid weather increases physiologic strain and headache risk 3
• Current or recent illness (especially with fever or gastrointestinal symptoms) increases vulnerability 3
• Poor heat acclimatization and inadequate hydration are modifiable risk factors 3

Preventive actions for hot conditions:

• Provide readily accessible fluids at regular intervals 3
• Allow gradual adaptation to climate and exercise intensity 3
• Decrease duration/intensity of warm-up in extreme heat 3
• Increase frequency and duration of breaks, preferably in shade 3

When to Pursue Further Evaluation

Red flags suggesting secondary causes requiring workup:

• Older age at onset (though less relevant in teenagers) 5
• Prolonged headache duration beyond typical exercise headache pattern 5
• First or worst headache ever experienced 6
• Headache exclusively in the morning with severe vomiting 6
• Progressive worsening in severity or frequency 6

If red flags present: Neuroimaging and comprehensive evaluation are warranted to exclude structural abnormalities, though standard imaging is typically normal in primary exercise headache. 5

Return to Activity Protocol

If headache was potentially concussion-related:

• Complete symptom resolution at rest AND with exertion is required before beginning return-to-play 1, 4
• Follow structured 5-day minimum stepwise protocol: light aerobic activity → sport-specific exercise → non-contact drills → full-contact practice → return to play 1, 4
• Each step requires minimum 24 hours and complete absence of symptoms 1, 4
• If symptoms return at any stage, stop immediately and return to previous asymptomatic level after 24 hours rest 4

If primary exercise headache (no trauma):

• Focus on trigger avoidance through proper warm-up techniques 2
• Implement environmental modifications and hydration strategies 3, 2
• Consider prophylactic NSAID use before activity if headaches are predictable 2, 5

Critical Pitfalls to Avoid

• Never dismiss headache after any head impact as "just exercise headache"—concussion must be ruled out first, as 80-90% of concussions involve headache 3, 1
• Never allow same-day return to play if concussion is suspected, even if the teenager feels completely better 1, 4
• Don't overlook heat illness as a contributing factor, especially in inadequately acclimatized teenagers exercising in hot/humid conditions 3
• Don't assume all exercise headaches are benign—10% have organic causes requiring investigation 2