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In the beginner’s mind there are many possibilities, in the expert’s mind there are few.

Shunryu Suzuki, Zen Mind, Beginner’s Mind

Headache is one of the most prevalent pain conditions present at all stages of life. It affects the majority of the global population and is among the top 10 causes of disability.1 Despite this, the burden of headache has been largely underestimated, with headache disorders often dismissed as minor and undeserving of medical care.1, 2 Although athletes suffer from the same causes of headache as non-athletes, there are several key causes of headache that relate directly to exercise or to the sport itself. An additional factor to consider is that headache can impair both training and sports performance.

The International Headache Society (IHS) classifies headache into a range of disorders comprising three broad categories with more than 300 underlying headache forms.3 The majority of these disorders are not particularly relevant to an athletic population or the IHS definitions do not adequately cover the symptoms experienced by athletes.4 Figure 21.1 lists the broad classification according to the IHS and the common headache disorders seen in sport.

Figure 21.1

Classification of headache


The prevalence of headache directly related to sport has been poorly investigated or reported, although there is increasing attention in contact sport on concussion or trauma-related headache.5 In a New Zealand university setting, 35% of athletes surveyed reported headaches, both traumatic and non-traumatic.6 Importantly, 54% of people who reported headache associated with sport or exercise gave up their activity.7 In some codes of football, more than 50% of athletes experience regular headaches from matches and training.4

While the latest edition of the IHS headache classification is comprehensive, it is not aimed specifically at a sporting setting. Williams and Nukada proposed a simple framework for specific sporting headaches.8 This included:

  • effort-exertional headache

  • effort migraine

  • trauma-triggered migraine

  • post-traumatic headache.

An alternative sports-specific headache organisational framework has been proposed that incorporates the non-sporting as well as sporting headaches.9 Headaches are categorised as follows:

  • a recognised headache syndrome (migraine, tension-type headache, cluster headache) coincidental to sporting activity

  • headache arising from mechanisms that occur during exertion; these can be primary (mechanism unknown) or secondary where a causal factor can be demonstrated, such as a headache:

    • related to changes in cardiovascular parameters

    • related to trauma

    • arising from structures in the neck

    • arising from mechanisms that are specific to an individual sport.


Headache is an unusual condition being both a symptom and a disease, which can make diagnosis and management challenging. Of primary importance is identifying when headache is ...

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