Version July 2025
INTRODUCTION —
Primary exercise headache is an uncommon headache syndrome characterized by episodes of head pain triggered exclusively by exercise.
This topic will discuss primary exercise headache, previously called exertional headache. Other uncommon headache syndromes characterized by recurrent episodes of triggered head pain are discussed separately.
●(See "Overview of thunderclap headache".)
●(See "Primary cough headache".)
●(See "Primary headache associated with sexual activity".)
●(See "Cold stimulus headache".)
PATHOPHYSIOLOGY —
The pathophysiology of primary exercise headache is not well understood. Most theories center on the transmission of increases in intra-abdominal/intrathoracic pressure into the cranium via the venous system with distension of, or traction on, pain-sensitive vascular and meningeal structures [1]. Possible contributing mechanisms include:
●Jugular vein valvular incompetence – Incompetence of the internal jugular vein valve might play a role in the development of primary exercise headache by predisposing to increased cerebral venous congestion and elevated intracranial pressure during exertion or other Valsalva-like maneuvers. One study using venous duplex ultrasound to compare 20 patients with exercise headache and 40 controls found that retrograde jugular venous flow during Valsalva was significantly more frequent in patients with exercise headache than controls (70 versus 20 percent, respectively) [2].
●Impaired cerebrovascular autoregulation – Impaired autoregulation of cerebrovascular smooth muscle has been posited to account for both primary exercise headache and primary headache associated with sexual activity [3]. This dysregulation may impair the ability of resistance vessels to respond adequately to increased blood pressure during exertion, resulting in abnormal vasodilation, vessel wall edema, or increased cephalic blood volume [4].
●Trigeminovascular activation – A susceptibility to primary exercise headache may also be related to the activation of trigeminal nociceptors in the brainstem, a shared mechanism with migraine (see "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults"). Both conditions may be triggered by exertion and can have similar clinical features. However, it is unclear why some individuals with exercise headache become vulnerable to repeated activations of trigeminocervical nociceptive neurons since similar transient increases in intracranial pressure due to Valsalva presumably occur in everyone. Possibilities include:
•Lowered activation thresholds in first- or second-order nociceptive trigeminocervical neurons,
•Alterations in central nociceptive processing, AND
•Other factors that result in inordinately large fluctuations in intracranial pressure.
EPIDEMIOLOGY —
The precise incidence and prevalence of primary exercise headache are unknown but may be underreported. Some patients with mild or infrequent symptoms may never come to clinical attention. Others with initial symptoms may choose to avoid triggering activity, while some susceptible individuals who do not engage in sustained or vigorous exercise may never develop symptoms [5].
A Danish population-based study of adults found that benign exercise headache had a lifetime prevalence of 1 percent [6], while a study of adults from Norway found a prevalence of approximately 12 percent [7]. In an Iranian general population cohort of 2300 people, exercise headache was more frequent in females compared with males (10.0 versus 5.4 percent) with an overall one-year prevalence of 7.3 percent (95% CI 6.2-8.4) [8]. One large series carried out in athletes (cyclists) estimated a considerably higher prevalence of 26 percent [9].
Limited data suggest exercise headache occurs more commonly among females, up to a 2:1 female:male ratio [8,10].
Primary exercise headache occurs in both children and adults [8,11]. The mean age at presentation is approximately 24 years [12]. New onset of exercise headache symptoms in middle-aged patients is associated with an increased risk of a secondary (structural) cause of symptoms [13]. (See 'Secondary exercise headache' below.)
CLINICAL FEATURES —
Primary exercise headache is characterized by episodes of pulsatile head pain that are brought on by and occur only during or after physical exercise.
●Headache character – Primary exercise headache attacks are throbbing in quality and may be mild, moderate, or severe in intensity. Most patients report bilateral or diffuse headaches, but some may have unilateral symptoms [10]. Duration ranges from five minutes up to 48 hours, with most lasting for several hours [14].
Attacks are triggered by physical exercise that is usually vigorous and may be prevented by avoidance of excessive physical exertion. The headache typically begins within 30 minutes after exertional onset [8,14]. Exercise headaches are not usually associated with nausea or vomiting [15].
Some patients with exercise headache may have atypical features such as unilateral focal location (eg, temporal region), very brief duration (eg, <5 minutes), or delayed onset (eg, >1 hour after exercise) because the defining features of exercise headache are based on a relatively small number of patients in several case series [4,5,8,12,15-18].
●Exercise triggers and risk factors – Several types of exercise may trigger exercise headache attacks, including resistance training, swimming, bicycle riding, running, basketball, and skiing [9-11]. For many patients, the intensity of exertion is correlated with the likelihood of developing an exercise headache attack. For others, vigorous physical activity may trigger exercise headache attacks intermittently [8].
Primary exercise headache has also been associated with exercise in hot weather and at high altitude [5,19].
DIAGNOSIS —
The diagnosis of primary exercise headache should be considered in patients who develop headache during or after physical exertion. The diagnosis is made in patients whose symptoms fulfill diagnostic criteria after excluding alternative causes to symptoms.
Diagnostic criteria — The diagnosis of primary exercise headache, according to the International Classification of Headache Disorders, 3rd edition (ICHD-3), requires fulfilling all of the following criteria [19]:
●At least two headache episodes
●Brought on by and occurring only during or after strenuous physical exercise
●Lasting <48 hours
●Not better accounted for by another ICHD-3 diagnosis
Evaluation — Diagnostic testing is warranted in all patients with clinical features of exercise headache to exclude underlying structural and metabolic causes of symptoms. We perform imaging on all patients and also perform a cardiac evaluation for those with symptoms or risk factors for cardiac causes.
Neuroimaging — We suggest brain and vascular imaging for patients with features of new-onset primary exercise headache to identify structural and vascular causes of symptoms. Some patients with clinical features consistent with primary exercise headache may have alternative underlying causes that require specific treatment.
Patients with acute symptoms — Imaging is warranted for patients presenting with new exercise headache symptoms. Patients with abrupt onset headache require urgent evaluation, and other symptomatic patients with new onset exercise headache and risk factors for a secondary headache require prompt evaluation. Specific testing varies by clinical features.
●For patients with abrupt onset (ie, "thunderclap") headache during exercise, evaluation starts with urgent testing to exclude subarachnoid hemorrhage (SAH) (algorithm 1). This typically includes urgent head computed tomography (CT) followed by lumbar puncture if head CT is nondiagnostic. Angiography may also be required to identify or exclude a cerebral aneurysm. (See "Overview of thunderclap headache", section on 'Diagnostic evaluation'.)
After SAH is excluded, additional brain and cerebrovascular imaging is warranted (if not already performed) to exclude other conditions such as cervical arterial dissection or intracranial neoplasm. We prefer brain magnetic resonance imaging (MRI) with contrast and either CT angiography or MR angiography of the head and neck.
●For symptomatic patients with new-onset exercise headache who have features suggestive of a secondary headache syndrome, we perform prompt brain and vascular imaging at the time of presentation. These features include any of the following:
•Patient age >50 years
•History of neoplasm, recent trauma, hypercoagulable state, or anticoagulant therapy
•Nausea and/or vomiting
•Neurologic deficits (eg, papilledema, focal weakness, speech impairment)
•Neck and/or eye pain
•Syncope or seizure
We typically start with a head CT and either CT angiography or MR angiography of the head and neck. We also perform brain MRI with contrast if initial imaging is nondiagnostic. (See "Evaluation of headache in adults", section on 'Choice of imaging exam'.)
●For other symptomatic patients with new-onset exercise headache without features of a secondary headache syndrome, we typically obtain brain MRI with contrast and either CT angiography or MR angiography of the head and neck.
In a retrospective series that included 28 patients with headache triggered by exercise, an intracranial abnormality was found in 12 (43 percent) [12]. The patients in this series with secondary headaches generally had symptoms strongly suggestive of an intracranial abnormality, including sudden explosive onset, vomiting, and focal neurologic deficits such as diplopia or papilledema.
Patients with prior or recurrent symptoms — Patients who present with a history of one or more episodes of exercise headache warrant evaluation for structural lesions. We typically perform brain MRI with contrast along with MR angiography of the head and neck. Head CT with contrast and CT angiography of the head and neck can be performed as an alternative modality for patients unable to undergo MRI.
In one early series of 103 patients who presented with exercise (including cough-triggered) headache and a normal neurologic examination, an intracranial lesion was found in 9.7 percent [15]. In a subsequent review of 219 nonconsecutive patients with either exercise headache or cough headache, a structural lesion was found in 22 percent [18]. However, some of these patients may have had atypical features or abnormal findings on a neurologic examination that prompted imaging.
Cardiac evaluation — We perform a cardiovascular evaluation for patients with exercise headache who have nondiagnostic imaging and a high cardiovascular risk profile (calculator 1) or clinical features suggestive of myocardial ischemia including:
●Associated neck/jaw or chest pain
●Associated dyspnea
●Atypical or mild headache
Specific testing varies by clinical setting:
●For patients with acute headache symptoms, testing typically includes an electrocardiogram and cardiac biomarkers such as high-sensitivity troponins. (See "Diagnosis of acute myocardial infarction".)
●For others with recurrent or chronic symptoms, we typically refer patients for cardiology evaluation including a cardiac stress test. (See "Selecting the optimal cardiac stress test".)
In case reports, patients with exercise headache have been found to have cardiac ischemia identified on electrocardiogram or stress testing, and headache symptoms have responded transiently to nitrates and subsequently resolved following coronary artery revascularization [20,21].
DIFFERENTIAL DIAGNOSIS —
The differential diagnosis of primary exercise headache includes other primary headache conditions that may be triggered by exercise as well as intracranial, cardiac, and systemic conditions that may produce headaches in the setting of vigorous exercise.
Primary headache syndromes
●Cough headache – Because Valsalva maneuvers frequently occur in the context of many forms of physical exertion, it is sometimes difficult to distinguish primary cough headache from primary exercise headache. Both primary headache disorders may coexist [10]. However, several clinical differences between benign cough and benign exercise headache have been identified [12]. Cough headache is triggered by Valsalva maneuvers, while exercise headache is triggered by sustained physical exercise. In addition, primary cough headache attacks are typically sharp and stabbing in quality, typically last seconds to minutes, and occur within seconds to minutes. By contrast, exercise headaches are pulsatile, typically last hours, and often occur within 30 minutes after exertion onset.
●Migraine – Both exercise headache and migraine may feature pulsatile head pain that can persist for hours, and some patients with migraine report exercise as a trigger. However, migraine is more frequently unilateral and associated with nausea and vomiting. In addition, aura is not a feature of exercise headache, and patients with exercise-triggered migraine also have headache attacks unrelated to exercise.
Of note, migraine can be comorbid with exercise headache [5].
●Primary headache associated with sexual activity – Both exercise headache and primary headache associated with sexual activity are associated with an exertional trigger. However, the defining triggers are distinct.
Exercise headache can be comorbid with primary headache associated with sexual activity.
Secondary exercise headache — Several structural and systemic conditions may present with exercise-triggered headache. They are typically identified by specific additional clinical features or by results of diagnostic evaluation. These conditions include the following:
●Intracranial structural conditions – Some intracranial structural conditions may present with acute symptoms that begin during exercise. Changes in cardiac output or intracranial pressure during exercise may trigger the onset of headache. Such structural conditions are typically identified with brain imaging and include:
•Acute cerebrovascular event (eg, intracerebral or subarachnoid hemorrhage [SAH]) [12,22] (see "Spontaneous intracerebral hemorrhage: Acute treatment and prognosis" and "Stroke: Etiology, classification, and epidemiology")
•Chiari I malformation [12] (see "Chiari malformations")
•Neoplasms and other space-occupying lesions (eg, colloid cyst of the third ventricle) [12,18] (see "Overview of the clinical features and diagnosis of brain tumors in adults" and "Uncommon brain tumors", section on 'Colloid cyst')
●Idiopathic intracranial hypertension – Headache is the most common presenting feature of idiopathic intracranial hypertension (IIH, also called pseudotumor cerebri) and may worsen with or be triggered by exercise.
However, patients with IIH also typically have headaches in other settings and may report additional clinical features such as visual loss, diplopia, or tinnitus, all features uncommon with exercise headache. IIH is suspected in individuals with headache and/or papilledema and may be diagnosed in suspected patients by identifying evidence of elevated intracranial pressure on ophthalmologic examination, brain MRI findings, and/or lumbar puncture. (See "Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis".)
●Vascular conditions – Cervical and intracranial vascular conditions that may uncommonly present with exercise-related headache also typically feature focal neurologic deficits such as Horner syndrome, hemiparesis, or speech impairment. These conditions are typically identified with brain and/or vascular imaging and include:
•Reversible cerebral vasoconstriction syndrome (RCVS) [23,24] (see "Reversible cerebral vasoconstriction syndrome")
•Cervical (carotid or vertebral) artery dissection [25-28] (see "Cerebral and cervical artery dissection: Clinical features and diagnosis")
●Cardiac and systemic conditions – Myocardial ischemia [20,29] and some systemic conditions that result in blood pressure fluctuations (eg, pheochromocytoma [30]) may present with headache and other symptoms triggered or exacerbated by exercise. In some cases, exercise-related headache may be the only symptom. These conditions are identified by cardiac and laboratory testing when suspected in patients with cardiac risk factors or additional symptoms atypical for primary exercise headache. (See "Diagnosis of acute myocardial infarction" and "Clinical presentation and diagnosis of pheochromocytoma".)
TREATMENT —
Treatment of primary exercise headaches is usually prophylactic or preemptive when exercise is predictable.
Nonpharmacologic strategies — For all patients with primary exercise headache, we start with nonpharmacologic strategies. Some patients with exercise headache may benefit from acclimatizing efforts such as starting exercise with a warm-up period and engaging in a regimen of progressively increasing intensity of peak exertion over a several week period [5]. Others with symptoms triggered by heat or high elevations may attempt to limit exposure to these factors.
Patients should avoid constrictive headwear and limit traction on the hair (eg, from a ponytail or braiding), as these factors may cause external pressure headaches and exacerbate symptoms.
Preventive medications — For patients with exercise headache who desire treatment, we suggest indomethacin over other agents. Limited data suggest indomethacin may be effective for patients with exercise headache [31,32]. Alternative agents for patients who do not respond to indomethacin include other nonsteroidal antiinflammatory drugs (NSAIDs) and beta-blockers.
●Indomethacin – We typically start indomethacin at 25 mg given once prior to exercise and increase by 25 to 50 mg intervals each week as needed and tolerated up to a typical maximum dose of 200 mg. We typically advise timing the dosing 30 to 60 minutes before activity/exercise. Patients with frequent exercise headaches may prefer to take indomethacin on a daily basis.
Gastroprotection with proton pump inhibitors (PPIs) is typically indicated for all patients who require long-term indomethacin treatment (see "NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity"). We also use PPIs for those who require long-term indomethacin treatment.
The mechanism of indomethacin in exercise headache is not known, although its effect on cerebrospinal fluid pressure has been suggested [33]. In one series of 15 patients with primary exercise headache, a favorable response of >75 percent reduction in headache frequency was reported by 11 (73 percent) within two weeks of starting therapy [16]. The daily dosing ranged from 25 to 150 mg.
●Alternative options – Other agents that may be beneficial for patients with exercise headache include other NSAIDs such as naproxen sodium or beta-blockers such as propranolol, metoprolol, or atenolol [12,34]. These agents are typically administered 30 to 60 minutes before exercise but may be given daily for patients with frequent or daily exercise headaches. Naproxen sodium (200 to 750 mg) may be preferred by patients who wish to avoid the risk of blunting aerobic exercise performance associated with beta-blockers. Propranolol (40 to 120 mg) may be preferred by patients with gastroduodenal or other drug-class-related adverse effects with initial indomethacin treatment.
We typically continue effective therapy for three to six months before attempting to wean. Exercise headache may spontaneously resolve in many patients (see 'Prognosis' below). Therapy may be resumed if headaches recur.
PROGNOSIS —
Limited data suggest the prognosis of primary exercise headache is favorable with many patients reporting symptom control with preventive therapy or spontaneous resolution over the long-term [10]. In one series that followed 93 patients, complete remission of headache within five years was observed in 32 percent, and significant improvement or complete remission after 10 years was noted in 78 percent [15].
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Migraine and other primary headache disorders".)
SUMMARY AND RECOMMENDATIONS
●Definition and epidemiology – Primary exercise headache is characterized by episodes of head pain triggered exclusively by sustained or vigorous exercise. The prevalence of primary exercise headache varies from 1 to as high as 26 percent and is more common among females with a mean age at presentation of approximately 24 years old. (See 'Introduction' above and 'Epidemiology' above.)
●Clinical features – Primary exercise headache is characterized by episodes of pulsatile head pain that are brought on by or occur only during or after physical exercise. Episodes typically occur within 30 minutes of starting exercise and last from five minutes up to 48 hours. (See 'Clinical features' above.)
●Diagnosis – The diagnosis of primary exercise headache is made in patients who fulfill diagnostic criteria after excluding alternative causes. (See 'Diagnosis' above.)
●Diagnostic evaluation – Diagnostic testing is warranted in all patients with clinical features of new-onset primary exercise headache to exclude underlying structural and metabolic causes of symptoms. We perform imaging on all patients and also perform a cardiac evaluation for those with symptoms or risk factors for cardiac causes. (See 'Evaluation' above.)
•Patients with abrupt onset (ie, "thunderclap") headache during exercise require urgent testing to exclude subarachnoid hemorrhage (SAH) (algorithm 1). For most other patients, we prefer brain MRI with contrast and either CT angiography or MR angiography of the head and neck. (See 'Neuroimaging' above.)
•We perform a cardiovascular evaluation for patients with exercise headache who have nondiagnostic imaging and features suggestive of myocardial ischemia or a high cardiovascular risk profile (calculator 1). (See 'Cardiac evaluation' above.)
●Differential diagnosis – The differential diagnosis of primary exercise headache includes other primary headache conditions that may be triggered by exercise as well as intracranial, cardiac, and systemic conditions that may produce headaches in the setting of vigorous exercise. (See 'Differential diagnosis' above.)
●Treatment
•Nonpharmacologic measures – For all patients with exercise headache, we start with nonpharmacologic strategies such as starting exercise with a warm-up period, engaging in a regimen of progressively increasing intensity of peak exertion over a several week period, or limiting exposure to triggers (eg, heat or high elevations). (See 'Nonpharmacologic strategies' above.)
•Medications – For patients with primary exercise headache who desire treatment, we suggest indomethacin over other agents (Grade 2C). We typically start indomethacin at 25 mg given once 30 to 60 minutes prior to exercise and increase by 25 to 50 mg intervals each week as needed and tolerated up to a typical maximum dose of 200 mg. We typically continue effective therapy for three to six months before attempting to wean. (See 'Preventive medications' above.)
Other agents that may be beneficial for patients with exercise headache include naproxen sodium, propranolol, metoprolol, or atenolol.
●Prognosis – Limited data suggest the prognosis of primary exercise headache is favorable with many patients reporting symptom control with preventive therapy or spontaneous resolution over the long-term. (See 'Prognosis' above.)
