What is the cause of my severe headaches brought about by physical activity?

Q: I am a 49-year-old woman. About 10 years ago, I half-squatted to pass urine and experienced an explosive headache whilst urinating.

In 2009, I started having constant headaches at the back of the right side of my head. The pain is a burning sensation which wakes me up at night. I have tried various types of muscle-relaxant medicine but they were of no help.

Last November, when passing urine, the explosive pain in my head struck again. The pain lingered for five minutes or so.

After this second attack, I do not feel normal any more. I have headaches that feel like there is a pressure forcing my eyelids to droop.

More pain is felt on the right side of my head, as well as my neck and shoulder. A pins-and-needles sensation can also be felt in my right arm, right middle back and right leg.

Line dancing is my hobby. However, after I started to dance again in April this year, I would be affected by a headache the very next day.

I have also been diagnosed with ocular myasthenia gravis, an autoimmune disease which affects certain muscles. I take a medication called mestinon that helps to open my right eyelid, which would droop from time to time.

When a headache strikes, both my eyelids would droop and mestinon has no effect. I have had tests and a brain scan, but doctors have found nothing unusual.

A: Headaches, like other chronic pain conditions, are often underappreciated.

It is hard for friends and loved ones to understand what it is like to live with chronic headaches as there are no physical signs that the person is unwell.

With regard to your severe explosive pain, what doctors would be concerned about is an abnormality in the blood vessels of the brain, for example, an aneurysm (swelling of the blood vessel) which could rupture and lead to a stroke.

It appears that you have been adequately investigated, having undergone all the tests required.

Once serious pathology is excluded, doctors can then focus on treating your headaches.

You may have "thunderclap" headaches, which are sudden and severe headaches.

Their cause may be unknown but some secondary causes include an aneurysm or a vasospasm, which is a spasm of blood vessels that restricts blood flow and could lead to tissue death.

The headaches may be precipitated by physical activity. In your case, they appear to be linked to dancing and urinating.

However, it appears that you also have a baseline chronic daily headache.

The key to treatment will be to use preventive medication.

These are drugs that can be taken daily to prevent and reduce the frequency and severity of headaches.

These include calcium channel blockers and non-steroidal anti-inflammatory medication. These are usually given for a period of time, say, six months, and then stopped if the headaches are under control.

You will also need expert help to precisely diagnose the type of headache that you are suffering from, as the appropriate treatment depends on the diagnosis.

DR Charles Siow
Consultant neurologist at Siow Neurology Headache and Pain Centre

This article was first published on June 19, 2014.
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