Altitude induced migraine.
Article Type: Case study
Subject: Migraine (Drug therapy)
Migraine (Diagnosis)
Migraine (Development and progression)
Migraine (Risk factors)
Migraine (Case studies)
Mountain sickness (Risk factors)
Mountain sickness (Complications and side effects)
Mountain sickness (Case studies)
Authors: Watson, David B.
Torres-Trejo, Alejandro
Gutmann, Ludwig
Pub Date: 01/01/2011
Publication: Name: West Virginia Medical Journal Publisher: West Virginia State Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 West Virginia State Medical Association ISSN: 0043-3284
Issue: Date: Jan-Feb, 2011 Source Volume: 107 Source Issue: 1
Accession Number: 248734351
Full Text: Introduction

Ascent to high altitude is associated with a variety of neurologic symptoms, most commonly headaches. High altitude is known to induce both migraine and non-migraine headaches, and is more common in those who previously suffered from headaches. (1) No reports were found in the literature of first migraine or probable migraine triggered at high altitude. We report a case of new onset headaches at altitude that did not resolve on return to the patients normal altitude and subsequently progressed to probable migraine without aura.

Case Report

The patient is a 23 year old male college student and division one collegiate football player without a history of recent or remote head injury or personal history of headaches. His headache began after flying with his team to Colorado and staying at an altitude of approximately 1800m for less than 24 hours. He reported seeing spots in his vision and "tracers" moving across his visual field for about 20 minutes, followed by development of a global mild-moderate headache. Over the next few hours the pain localized to the right frontal and retro-orbital areas. He denied nausea, photophobia or phonophobia, and the pain was not made worse with activity. After his initial visual complaints he did not report any other neurologic symptoms with his headache. The headache began before the team practiced that day, and he was treated with anti-inflammatories with minimal relief. He was able to participate fully in practice and in the following day's game despite the headache. On return to his home, the headache continued in a similar pattern for 10 days, then began to worsen, becoming more severe and developing a pulsatile quality, limiting his ability to practice due to worsening pain. He was treated by team physicians with tramadol, sumatriptan nasal spray, amitriptyline, and prednisone without any improvement.

He presented to the Headache Center after he had missed two full days of practice. He denied any use of supplements other than fish oil and protein shakes. His past history showed only some orthopedic injuries and surgical corrections. He did not smoke or use alcohol. He reported a history of migraines in his mother, but otherwise denied any significant family history. His review of systems revealed only mildly increased daytime sleepiness, with good sleep schedules and sleep hygiene.

His exam was unremarkable except for being 1.91 meters tall and weighing 134 kilograms. There was no papilledema, scalp tenderness, or neck range of motion limitations. MRI of the head (with and without contrast) was normal.

He was treated with 1mg of subcutaneous dihydroergotamine, 10mg of intramuscular metoclopramide, and increase in his prednisone dose from 40mg to 60mg with a rapid tapering schedule. By the following morning team trainers reported that his headache had resolved and he was symptom free. He was able to return to his normal practice schedule without incident, and has not had a recurrence of his headache. Due to the players graduation, long term follow-up is not available, but from personal communication with the team physician, the headache did not return while a student of the university.

Discussion

The International Classification of Headache Disorders-2 (ICHD2) defines High-altitude Headache (10.1.1) under the category 10.1: Headache attributed to hypoxia and/or hypercapnia with the following diagnostic criteria:

A. Headache with at least two of the following characteristics and fulfilling criteria C and D:

1. Bilateral

2. Frontal or frontotemporal

3. Dull or pressing quality

4. Mild or moderate intensity

5. Aggravated by exertion, movement, straining, coughing or bending

B. Ascent to altitude above 2500m

C. Headache develops within 24 hours after ascent

D. Headache resolves within 8 hours after descent (2)

High altitude illness risk factors include younger age, rate of ascent, altitude obtained, and living at low altitude at baseline. Various etiologies have been proposed, including intracranial hypertension, declines in barometric pressure, hypoxia, and dehydration. Treatment options for altitude headache include non-steroidal anti-inflammatories, aspirin, acetaminophen, and oxygen, with acetazolamide and dexamethasone showing evidence for prevention (3). Typically, however, altitude headaches resolve with return to lower altitudes. (2) Mack has reported a case of New Daily Persistent Headache in a child after high altitude camping, (4) but we could not find other reports in the literature of continuous headaches triggered at altitude and not resolved with descent.

Our patient's headache does not meet ICHD-2 criteria for HAH, but the presentation is suggestive that ascent to relatively high altitude can act as a trigger for the development of headache. The development of migraine headache with ascent to altitude is recognized in known migraine sufferers, but we could not find documentation of high altitude causing probable migraine in a patient without a previous history of migraine. Despite his lack of personal history of migraine, his family history suggests that he may be genetically predisposed toward migraine, with high altitude serving as a potent trigger for his first migraine headache.

Other possible explanations for our patient's headache include travel, stress, and changes in time zones, but the previous travel experience of this fifth-year senior would suggest that the main difference in this case was an ascent to higher altitude. The trigger in this case is possibly low barometric pressure, rather than hypoxia or hypercapnia seen in true HAH, although our patient does carry multiple risk factors for HAH, including his young age, living at only 293m, and a rapid ascent via airplane, albeit to only 1900m. Low barometric pressure's influence on migraine has not been satisfactorily evaluated, as conflicting results have been found in previous investigations, but has been theorized to cause depolarization of neurons within the trigeminovascular pain pathways. (5)

The triggering of migraine headache by ascent to high altitude in known migraine sufferers is well recognized, but this case suggests that high altitude induced headache (not High-Altitude Headache) may be the presenting headache in patients with no previous headache history and may lead to the progression to migrainous headache if left inadequately treated. A careful review of travel history should be included when patients present with new onset daily severe headaches of unclear etiology.

References

(1.) Silber E, Sonnenberg P, Collier DJ, et al. Clinical features of headache at altitude: a prospective study. Neurol. 2003; 60:1167-1171.

(2.) Headache Classification Subcommittee of the International Headache Society. The international classiication of headache disorders: 2nd edition. Cephalal. 2004; 24(s1):1-160.

(3.) Seto CK, Way D, O'Connor N, et al. Environmental illness in athletes. Clin Sports Med. 2005;24:695-718.

(4.) Mack K. What incites new daily persistent headache in children? Pediatr Neurol. 2004;31:122-125.

(5.) Martin VT, Behbehani M. Toward a Rational Understanding of Migraine Trigger Factors. Med Clin North Am. 2001;85:911-41.

David B. Watson, MD

Alejandro Torres-Trejo, MD

Ludwig Gutmann, MD

WVU School of Medicine, Department of Neurology, Morgantown
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