Can a person with migraine headaches (with or without aura) safely scuba dive, and what precautions, medication restrictions, and medical clearance are required?

Migraine and Scuba Diving Safety

Individuals with migraine without aura can generally scuba dive safely with appropriate precautions, but those with migraine with aura face increased risks and require careful medical evaluation before diving, particularly due to the potential for diagnostic confusion between aura symptoms and serious diving-related neurological emergencies.

Risk Stratification by Migraine Type

Migraine Without Aura

• Divers with migraine without aura (characterized by unilateral, pulsating headache lasting 4-72 hours with nausea/vomiting and both photophobia and phonophobia) can typically dive if their condition is well-controlled 1
• The primary concern is distinguishing between a typical migraine attack and diving-related complications such as decompression sickness or arterial gas embolism 2

Migraine With Aura - Higher Risk Category

• Migraine with aura presents significant safety concerns for scuba diving because aura symptoms (visual, sensory, speech, motor, or brainstem symptoms lasting 5-60 minutes) can be indistinguishable from serious neurological diving emergencies 1, 2
• A case report documented a pediatric diver with migraine with aura and patent foramen ovale (PFO) who developed headache with neurological symptoms during diving, highlighting the compounded risk 3
• The gradual spreading nature of aura symptoms over ≥5 minutes can mimic transient ischemic attack or decompression sickness, creating diagnostic confusion underwater or immediately post-dive 1, 4

Specific Diving-Related Headache Risks

Dive-Triggered Headaches

• Scuba diving can trigger headaches through multiple mechanisms: otic and paranasal sinus barotrauma, arterial gas embolism, decompression sickness, carbon dioxide retention, carbon monoxide toxicity, hyperbaric-triggered migraine, cervical strain, supraorbital neuralgia, and cold stimulus headache 2
• Swimming and diving activities themselves can precipitate sudden severe pulsating headaches with nausea, resembling exertional headache syndromes 5

Critical Diagnostic Dilemma

• Focal neurological symptoms during or after diving, even in known migraineurs, must be treated as a diving emergency (arterial gas embolism or decompression sickness) until proven otherwise 2
• This requires immediate treatment with 100% oxygen and urgent referral to a hyperbaric chamber facility 2

Medical Clearance Requirements

Pre-Dive Evaluation

• Obtain detailed migraine history including: frequency of attacks, presence and characteristics of aura, typical triggers, duration between attacks, and current preventive medication regimen 1
• Screen for patent foramen ovale (PFO), as the combination of PFO and migraine with aura significantly increases risk of paradoxical embolism during diving 3
• Ensure migraine is well-controlled with infrequent attacks (ideally <15 days per month, as chronic migraine with ≥15 headache days monthly indicates poor control) 1

Medication Considerations

• Avoid diving while taking medications that impair cognitive function or alertness, particularly benzodiazepines like alprazolam 6
• Triptans and NSAIDs used for acute migraine treatment are generally compatible with diving if the diver is asymptomatic and the medication has cleared 7, 4
• Preventive medications (beta-blockers, anticonvulsants like topiramate, CGRP antagonists, tricyclic antidepressants) should be stable and well-tolerated before diving 6, 8

Practical Diving Precautions

For Migraine Without Aura

• Avoid known migraine triggers before diving (sleep deprivation, dehydration, specific foods, stress)
• Do not dive during an active migraine attack or within 24-48 hours of resolution
• Maintain adequate hydration and avoid excessive physical exertion before diving
• Dive conservatively with proper ascent rates to minimize decompression stress

For Migraine With Aura - Heightened Restrictions

• Consider diving contraindicated if aura attacks are frequent (>1 per month) or unpredictable
• If cleared to dive, never dive during prodrome, aura, or headache phases
• Ensure at least 7 days symptom-free before diving
• Screen for and address PFO if present, as this combination substantially increases stroke risk 3, 4
• Dive only with experienced partners aware of the medical history who can recognize emergency symptoms

Emergency Protocol

If Headache or Neurological Symptoms Occur During/After Diving

• Immediately abort the dive safely and administer 100% oxygen at the surface 2
• Treat as arterial gas embolism or decompression sickness regardless of migraine history 2
• Contact Divers Alert Network (DAN) emergency hotline and arrange immediate hyperbaric chamber evaluation 2
• Do not attribute focal neurological symptoms to "just a migraine" in the diving context—this is a potentially fatal error 2

Common Pitfalls to Avoid

• Never assume neurological symptoms underwater or post-dive are migraine aura without excluding diving emergencies first 2
• Do not dive if taking sedating medications or if migraine control is suboptimal 6
• Avoid diving with untreated or unscreened PFO in migraine with aura patients 3
• Do not ignore the increased stroke risk in migraine with aura, which is further compounded by diving-related factors 4