UPDATE: This article was originally published by itself. As of May 5, 2015 we decided to include it as a part of our series “The A.P.E.X. Way”.

Strenuous, intense physical training can result in what are known as EXERTION HEADACHES. This article describes exertion headaches, what causes an exertion headache, what to do to avoid exertion headaches, and how to properly transition back into training after suffering from an exertion headache. The majority of the article centers on exertion headaches that result from lifting weights; however, there is a CrossFit specific section towards the end of the article, updated March 2014. Endurance athletes that experience exertion headaches after high intensity cardio will find the CrossFit section most helpful. This article is not intended to replace a medical visit. In fact, if you are reading this because you recently experienced an exertion headache, take a moment and schedule a medical visit.

WHAT IS AN EXERTION HEADACHE?

Exertion headaches are exercise-induced headaches that are correlated with training at a very high intensity. They most commonly occur after a set of a compound leg movement (i.e. leg press, squat, deadlift) performed to failure or close to failure. Right after the set, sometimes on the final rep, an intense headache occurs typically in the back of the head or in the temples. What scientifically occurs is a forced dilation (expansion) of the blood vessels in your brain beyond their normal thresholds. This puts pressure on the meninges, (small nerves that cover the brain) which causes the painful headache. Once the heart rate and blood pressure drop, the headache becomes less intense; however, the meninges remain extra sensitive, and are susceptible to future headaches if blood pressure or heart rate spike.

WHAT CAUSES AN EXERTION HEADACHE?

Exertion headaches occur when a combination of the following circumstances are true:

DEHYDRATION: Dehydration thickens your blood

VALSALVA MANEUVER (Holding Breath): This causes a dramatic spike in blood pressure

POOR NECK POSITION: Anything other than a neutral spine causes constrictions on the carotid arteries, the main arteries that deliver blood to the brain.

INCREASED HEART RATE: As a set progresses, your heart rate will steadily climb so that by the end of your set it can be close to (or above) your maximal heart rate.

HEAVY WEIGHT: The more weight on your body, the more blood pressure will rise while lifting it. Because legs are the strongest muscle group in the body, more weight is needed to reach a level of fatigue or failure. The correlation between heavy weight and an increase in blood pressure makes compound leg movements more risky than other movements.

The combination of elevated blood pressure, heart rate, thickened blood and constricted arteries can result in a devastating surge of blood attempting to enter the brain, forcibly expanding the arteriole walls and putting pressure on the meninges.

HOW LONG WILL THE HEADACHE LAST?

Exertion headaches have three phases:

INTENSE HEADACHE: The first phase is the intense, painful headache that occurs during or immediately after an intense workout. The pain is typically in the temples or back of head. The feeling can best be described as a grenade exploding in the head. The headache hits rapidly, and throbs painfully. This headache will not go away until there is a decrease in heart rate, blood pressure, and all activity has ceased. DULL HEADACHE: The second phase is a dull, fatiguing headache that can last for up to 2 weeks. It typically lingers wherever the initial phase of the headache was felt because that is the area that the meninges flared up. FULL RECOVERY: Full recovery depends on the severity of the initial headache and the quality of rest given to the body to recover. If the body is given the opportunity to heal, dull headaches are typically gone in 1 week. True full recovery, meaning the ability to perform at the same level as before the headache, will take approximately 2 months.

HOW CAN EXERTION HEADACHES BE PREVENTED?

To prevent an exertion headache:

HYDRATE: Drink enough water that you’re urine is clear or faintly yellow (never dark golden) the day before your lift and the day of, and continue to drink water during your workout. This will ensure that your blood can flow freely and smoothly through your blood vessels.

BREATHE: The valsalva maneuver is a valuable tool for creating stability in the thoracic cavity (torso area) that can help prevent lower back injuries during maximal lifts. It should not, however, be used during sets of multiple repetitions. When performing multiple repetitions, exhale during the positive phase and inhale during the negative phase. You can find more detailed information on breathing techniques here.

NEUTRAL SPINE: Unless performing a neck exercise, there is no need for the neck to be bent. Maintaining a neutral spinal alignment allows for proper circulation through the arteries and veins responsible for moving blood in and out of the brain. While “looking up” may mentally help keep the back straight during a squat or a deadlift, it is not essential. Keep the head and neck in a neutral position.

CONDITIONING: Developing a healthy heart and lungs that can handle high intensity training can be accomplished with regimented cardiovascular training. General conditioning along with interval training can help reduce the risk of exertion headaches by developing an efficient and healthy cardiovascular system that can handle the stress.

Training with a high level of intensity is part of improving the body’s performance potential, increasing size and strength; however, it can also create an opportunity for an exertion headache. To avoid exertion headaches during high intensity training sessions, build a solid cardiovascular base, be hydrated, breathe correctly, and maintain a neutral spine. Also, consider performing the larger compound leg movements at the beginning of the workout. Leg movements are inherently heavy, taxing exercises. Performing them early in the workout is safer because fatigue, exercise-induced dehydration, and a peaking heart rate won’t be part of the equation yet.

HOW DO I RECOVER FROM AN EXERTION HEADACHE?

There are some simple guidelines that will help with full recovery and full pre-headache performance:

STOP: Once an exertion headache occurs, STOP. Do not attempt to push through the rest of the training session, it will only worsen the headache and the duration of symptoms. MEDICAL VISIT: It is important to rule out any other underlying potential causes. Aneurysm’s, thunderclap headaches, and slipped discs may be potential causes for similar symptoms and must be ruled out. If it is an exertion headache, physicians may recommend rest, plenty of fluids and ibuprofen taken every 4 – 6 hours daily to help with the swelling of the meninges. Or, they may recommend something else which is why it is important to consult the physician. REST 1 WEEK: The initial rest phase should be a complete week of total rest from all physical activity, including practices, strength training, cardio, as well as recreational and competitive activities.

If steps 1 – 3 are done without any interruptions, then the headache should subside and the head should feel normal after 1 week. However, the body is still not ready at this point for pre-headache performance. At this point, download the A.P.E.X. app and begin the INCEPTION workout progression designed by me specifically for recovery from exertion headaches. Over the last decade I have fine tuned this program to incorporate the correct volume, introducing compound and lower body movements at the appropriate time, allowing for the highest percentage of full recovery within a 2 month window. Here are some guidelines for building back up to pre-headache performance:

PHASE 1 (2 WEEKS): Take two weeks off from any lower body exercises, performing only upper body exercises at 50 – 75% of your pre-headache weight. By the end of the two weeks, weight should be approaching pre-workout level. Introduce light cardio, no more than 70% of your Maximum Target Heart Rate (220-Age), for no more than 20 minutes. PHASE 2 (2 WEEKS): Introduce single-joint, isolateral leg exercises to the upper body strength program. This includes leg extensions, leg curls, hip adduction and abduction. This allows for strength maintenance without loading the frame. Attempting to do compound leg movements such as squats, leg press, or deadlifts prematurely can cause a flair-up of the meninges and another full-blown exertion headache. Begin increasing intensity of cardiovascular training slowly during this phase. PHASE 3 (4 WEEKS): Begin introducing compound leg movements at 50% OF PRE-HEADACHE WEIGHT. Slowly add back volume and weight each workout. Begin pushing the cardiovascular system.

If at any point during this recovery plan an exertion headache occurs, then go back to step one which was STOP. Repeat with physician visit, rest, and slow recovery. It is important to note that while 2 months of recovery does seem like a long time, these headaches can linger for over 6 months if the body is not allowed to heal. 2 months of strategic recovery is better than 6 months of bull-headed attempts to push through it.

CROSSFIT

Since the original post of this article in 2011, and my original post back in 2007, CrossFit has exploded in popularity and has become a huge part of the fitness culture. WOD’s, CrossFit Games, and CrossFit Gyms have saturated the fitness world internationally. The reason I mention this because we have noticed a gradual climb in emails, hits, and posts related to exertion headaches coming from CrossFitters. None of our A.P.E.X. Coaches are CrossFit Certified, A.P.E.X. is not affiliated with CrossFit in any formal way at this point; however, we are all here to train at a high level and I have a tremendous respect for any athlete willing to push themselves hard enough to cause an exertion headache. Here are some things to consider as a CrossFitter as it relates to exertion headaches:

OLYMPIC MOVEMENTS: CrossFit incorporates big, compound, technical movements such as snatches, power cleans, jerks, deadlifts and squats VALSALVA MANEUVER: Holding your breath can help protect your spine during Olympic movements by creating thoracic pressure, helping your abdominal wall create a stable core SUPER-SETS: CrossFit workouts, in general, combine big movements with cardio movements, or big movements with other big movements NO REST: CrossFit workouts tend to omit rest between exercises, thus heart rate and blood pressure steadily climb, also leaving no time for water consumption during the workout COMPETITION: Competition can help by tapping into adrenaline, resiliency, and a never-quit attitude that can mask pain

Big movements that put weight on your frame cause a spike in blood pressure. Holding your breath to improve posture during big movements also causes additional spike in blood pressure. Doing multiple exercises back-to-back without rest causes an additional spike in blood pressure, but mainly an increase in heart rate. An increase in both heart rate and blood pressure, in a competitive setting, while not being able to calm down or drink water, can lead to an exertion headache. It will not be early in the workout when you are calm, energetic, and focused, but towards the end when blood pressure and heart rate are peaking out, and your trying to overcompensate to finish the workout by holding your breath as your core fatigues.

CrossFit philosophy dictates that variables 1, 3, 4 and 5 are part of what makes CrossFit workouts intense, and that will not change. Many people have successfully completed WOD’s without causing an exertion headache; therefore, CrossFit workouts do not inherently cause exertion headaches. The key to preventing an exertion headache during bouts of intense exercise is coming into the workout rested, hydrated, and mentally focused. During the workout, you must maintain a good breathing cadence, making sure to exhale during the positive phase, and inhale during the negative phase of the movement. Late in the workouts when your blood pressure and heart rate are climbing, you must remain calm and focused, regulate your breathing, and concentrating on good body mechanics. If you do these things, you will be able to perform CrossFit style training free from exertion headaches.

If you do experience an exertion headache during a CrossFit workout, here is the recommended recovery timeline to get back to performing WOD’s at 100% pre-headache performance levels.

STOP: Once an exertion headache occurs, STOP. Do not attempt to push through the rest of the training session, it will only worsen the headache and the duration of symptoms. MEDICAL VISIT: It is important to rule out any other underlying potential causes. Aneurysm’s, thunderclap headaches, and slipped discs may be potential causes for similar symptoms and must be ruled out. If it is an exertion headache, physicians may recommend rest, plenty of fluids and ibuprofen taken every 4 – 6 hours daily to help with the swelling of the meninges. Or, they may recommend something else which is why it is important to consult the physician. REST 1 WEEK: The initial rest phase should be a complete week of total rest from all physical activity, including practices, strength training, cardio, as well as recreational and competitive activities.

If steps 1 – 3 are done without any interruptions, then the headache should subside and the head should feel normal after 1 week. However, the body is still not ready at this point for pre-headache performance. Here are some guidelines for building back up to pre-headache performance:

PHASE 1 (2 WEEKS): Focus on cardiovascular conditioning, introduce light cardio, no more than 70% of your Maximum Target Heart Rate (220-Age), for no more than 20 minutes. Jogging, running, swimming, and hiking are the types of cardio to do during phase 1. PHASE 2 (2 WEEKS): Begin pushing your cardiovascular system to closer to 90% of your Maximum Target Heart Rate, introducing rowing and other body-weight exercises (burpees, air squats, vertical jumps, lunges, jumping jacks, etc.). There are “No Equipment” CrossFit workouts that you can test yourself on, seeing how well you can handle intensity before adding in weights. PHASE 3 (4 WEEKS): Week 1, do WOD’s at 50% of pre-headache WEIGHT and TOTAL VOLUME. Week 2, do WOD’s at 50% of pre-headache weight, but normal VOLUME. Week 3, up the weight to 75% of pre-headache weight. Week 4, attempt with caution, pre-headache weights.

During PHASE 1 and PHASE 2, focus on hydration, breathing, and sleep, and listen to your body. If you feel like a flair-up may happen, STOP. The key is getting through PHASE 1 and 2 without a headache while performing at a high level. Before moving into PHASE 3, you should be dominating body weight WOD’s without any fear of a headache. For PHASE 3, use the following example for clarification.

EXAMPLE: WOD – 10 rounds, 10 snatches @ 100 kilos / 30 seconds of speed rope

PHASE 3, WEEK 1: 5 rounds, 10 snatches @ 50 kilos / 30 seconds of speed rope (50% WEIGHT & VOLUME) PHASE 3, WEEK 2: 10 rounds, 10 snatches @ 50 kilos / 30 seconds of speed rope (50% WEIGHT) PHASE 3, WEEK 3: 10 rounds, 10 snatches @ 75 kilos / 30 seconds of speed rope (75% WEIGHT) PHASE 3, WEEK 4: 10 rounds, 10 snatches @ 100 kilos / 30 seconds of speed rope (100% WEIGHT)

The key is to slowly re-introduce weight while under stress. PHASES 1 and 2 should have prepared your blood vessels for the increase of heart rate, but the spike in blood pressure comes with additional weight on your frame. Remember, if at any point you experience an exertion headache, you are back to STOP, a MEDICAL VISIT, and 1 FULL WEEK OF REST, so don’t try to skip ahead, it will only delay your full recovery.

FINAL thought

Those of us that have experienced exertion headaches are like pit bulls. We have a high pain tolerance, we push ourselves beyond normal limits, and we are stubborn as hell if we are told to take some time off for any injury, especially one that doesn’t involve a torn muscle or a broken bone. We all believe we are the exception, and that we can heal like Wolverine. Remember, an EXERTION HEADACHE is an INJURY TO THE BRAIN. If not taken seriously, it won’t go away and can become worse. Just like any other injury, certain steps must be taken to transition the body back to a high performance level again. So from one pit bull to another, please take the next 2 months to slowly recover and get back to pre-headache performance levels. If you think you are the exception, you’re not. Hopefully you find this article to be helpful. If you have any questions, email me at nick@apexllc.org. You can also find other helpful articles on our website at www.apexllc.org. Thanks!

Nick Ryan, CSCS