“A student approached me after one of my indoor cycling classes, complaining of an intense headache and asking me what I thought. I didn”™t know what to say, so I just told her to see her doctor! Any thoughts?”

- S.H., Darien, NY

Melissa writes:

First off, kudos to you for having the courage to acknowledge the limits of your expertise. You did exactly the right thing to refer your student to see her physician.

Exercise-induced, or exertion headaches are yet another incompletely understood phenomenon (that tends to be what I end up writing about on ICI/PRO, after all!). Headaches that occur during or immediately after exercise are well-described in the literature and are thought to be quite common: it is estimated that 1 out of 100 people experience at least one exertion headache at some point in their lives1. However, large prospective studies are lacking to identify exactly what causes them2.

We can think about exertion headaches as one of two flavors: primary, which are not connected to any underlying problems, and thus not serious, and secondary, attributable to some other, potentially serious medical problem but triggered by exertion. Most exertion headaches are primary. Exertion headaches are often described as “throbbing” bilateral (both sides) pain, lasting anywhere from 5 minutes to 48 hours. Secondary exertion headaches can also include vomiting, visual changes, and neck stiffness, and can last for several days3.

We know that exertion headaches occur under conditions of “strenuous” activity. But why?

The leading theory on headache, migraine or otherwise, is that it is related to changes in blood flow to the brain (both increased and decreased flow — all that counts is that there is a change). Revving up one”™s system, perhaps due to inadequate warm-up, or starting an intense training program without appropriate build-up, indeed causes changes in blood flow all over, which influences blood flow to the brain4. Even during responsible exercise, there is increased oxygen demand not only in skeletal and cardiac muscle but also to the brain. To increase blood flow to the brain to enhance oxygen delivery, the vessels of the brain dilate. It is this exercise-induced vasodilation which can cause headache5.

Moreover, exercising in warm conditions (i.e., outside on a hot summer day, improperly ventilated Spinning studio) can independently lead to vasodilation (think: heat dilates vessels; cold constricts vessels — we”™ll revisit this later).

Hypoglycemia, or low blood sugar, can also cause headache6. Reminding students to make sure that they eat something (check out ICI Podcast #3 with dietitian Tyler Young on tips for pre- and post-exercise fuel) before and after they train, and during exercise for a training session lasting longer than 60 minutes, is an important responsibility we as instructors should take seriously. Our nutritional fuel has major ramifications for our metabolic adaptations during and after exercise, which I will describe in an upcoming ICI column.

So what to do about exertion headaches?

Anyone who experiences an exercise-induced headache (intense pain during or after strenuous exercise) for the first time should see their physician for evaluation, as well as anyone who experiences changes in their exercise-induced headaches. After determining that these headaches are not the result of an underlying problem, the physician will often prescribe an anti-inflammatory drug (like indomethacin, which constricts blood vessels) for the athlete to take immediately when he or she feels a headache coming on7.

But the mainstay of exertion headache treatment is prevention, through the reduction of risk factors. Proper warm-up before exercise, proper cooling and ventilation of exercise settings, as well as adequate sleep, nutrition and hydration can reduce the occurrences of exertion headaches8.

In addition, research supports the use of head-cooling for the treatment of headaches. Just as heat causes the blood vessels in the brain to dilate, cold causes the same vessels to contract. By applying ice packs around the head or submersing large portions of the head in ice water (i.e., under a faucet or a locker room shower immediately after indoor cycling class), this can reverse the vasodilation process and stop the headache9. Neat, huh? (And while anecdotes don”™t mean much, this is how I treat my own exercise-induced vasodilation headaches. Works every time.)


Exertional or exercise-induced headaches are a common but incompletely understood phenomenon. Most exertional headaches do not reflect any serious medical problem. However, if someone experiences a headache during or after exercise for the first time, or a headache more severe than usual, he or she should see their doctor for evaluation.

Like all other recommendations to prevent, well, anything: Warm-up. Exercise in ventilated areas. Sleep enough, eat enough, drink enough. Once option maybe to use a Chill-Its Cooling Towel. And if all else fails, stick your head under the sink under the most frigid water you can bear.

Melissa Marotta is a Family Medicine Resident Physician at Middlesex Hospital. She is also a STAR 3 Spinning Instructor, Certified Personal Trainer (ACE), and author.

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  1. Exercise Headaches. Mayo Clinic. http://www.mayoclinic.com
  2. Turner, J. Exercise-related Headache. Current Sports Medicine Reports: Feb 2003 — 2(1).
  3. Exercise Headaches. Mayo Clinic. http://www.mayoclinic.com
  4. Nadelson, C. Sport and Exercise-induced Migraines. Current Sports Medicine Reports: Feb 2006: 5(1): 29-33.
  5. Turner, J. Exercise-related Headache. Current Sports Medicine Reports: Feb 2003 — 2(1).
  6. Ibid.
  7. Exercise Headaches. Mayo Clinic. http://www.mayoclinic.com
  8. Nadelson, C. Sport and Exercise-induced Migraines. Current Sports Medicine Reports: Feb 2006: 5(1): 29-33.
  9. Singh RK, Martinez A, Baxter P. Head Cooling for Exercise-Induced Headache. J Child Neurol 2006;21:1067-1068

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