Primary Exertional Headache: Updates in the Literature
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UNCOMMON HEADACHE SYNDROMES (J AILANI, SECTION EDITOR)
Primary Exertional Headache: Updates in the Literature Rashmi B. Halker & Bert B. Vargas
Published online: 19 April 2013 # Springer Science+Business Media New York 2013
Abstract Primary exertional headache (PEH) has been recognized by the International Headache Society as a primary headache diagnosis since 1994. It is an uncommon, self-limited, and short-lasting disorder that is precipitated by exertion and is frequently comorbid with migraine. PEH shares a number of features with other headache disorders, including thunderclap headache, primary cough headache, and headache associated with sexual activity. Upon its initial occurrence, PEH requires a thorough neurologic evaluation and imaging studies to help eliminate possible underlying secondary causes, including subarachnoid hemorrhage and sentinel bleed. Although PEH is incompletely understood with regard to its epidemiology and pathophysiology, it is generally considered to be a benign disorder that is self-limited and responsive to trigger avoidance and indomethacin. Keywords Exertional headache . Cough headache . Headache associated with sexual activity . Indomethacinresponsive . Migraine . Thunderclap headache
or at high altitudes, lasting 5 min to 48 h, brought on exclusively during or after physical exertion, and not attributed to any other disorder [1]. Up to 50 % of patients with PEH and primary headache associated with sexual activity report that they also have headaches meeting criteria for migraine [1]. Although PEH shares several features with other primary headache disorders such as primary cough headache and primary headache associated with sexual activity, primary exertional headache is unique in that it requires sustained physical exercise, rather than a shortduration exertion such as coughing, sneezing, Valsalva, or orgasm to trigger the headache [2••]. The initial evaluation of PEH should always include a workup for vascular and structural abnormalities typically associated with thunderclap headache, after which judicious application of diagnostic criteria should be utilized to help ensure an accurate diagnosis, thereby helping to formulate an effective treatment plan.
Epidemiology Introduction Primary exertional headache (PEH) is an uncommon primary headache disorder defined by the second edition of the International Classification of Headache Disorders (ICHD-2) as a pulsating headache, typically triggered in hot weather This article is part of the Topical Collection on Uncommon Headache Syndromes R. B. Halker (*) : B. B. Vargas Department of Neurology, Mayo Clinic College of Medicine, Scottsdale, AZ 85259, USA e-mail: [email protected]
PEH was first described in 1968 by Rooke, who published a case series of 103 patients with exertional headache, 93 of whom were felt to have benign underlying causes [3]. With these results, Rooke concluded that exertional headache may be a primary headache disorder. The International Headache Society (IHS) identified “benign exertional headache”
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