Swimmer’s Headache

Abstract

Tension-type headache, formerly known as muscle contraction headache, is the most common type of headache that afflicts humankind. It can be episodic or chronic, and it may or may not be related to muscle contraction. Tension-type headache is usually bilateral but can be unilateral; it often involves the frontal, temporal, and occipital regions. It may present as a bandlike, nonpulsatile ache or tightness in the aforementioned anatomic areas. Although both sexes are affected, female patients predominate. Antidepressants are generally the drugs of choice for the prophylactic treatment of tension-type headache and can be used in combination with cervical epidural nerve blocks. The avoidance of addicting medications, coupled with the appropriate use of pharmacologic and nonpharmacologic therapies, should result in excellent palliation and long-term control of pain in most patients suffering from this headache syndrome.

Keywords

tension-type headache, headache, antidepressants, cervical epidural block, bilateral headache, muscle contraction headache, migraine headache, Arnold-Chiari malformation

ICD-10 CODE G50.8

The Clinical Syndrome

Swimmer’s headache is seen with increasing frequency owing to the growing number of people who are swimming as part of a balanced program of physical fitness. Although an individual suffering from swimmer’s headache most often complains of a unilateral frontal headache that occurs shortly after he or she begins to swim, this painful condition is more correctly characterized as a compressive mononeuropathy. Swim goggles that are either too large or too tight compress the supraorbital nerve as it exits the supraorbital foramen and cause swimmer’s headache ( Fig. 5.1 ). The onset of symptoms is insidious in most patients, usually after the patient has been swimming for awhile, and is caused by prolonged compression of the supraorbital nerve. Several reported cases of acute-onset swimmer’s headache have a common history of the patient’s suddenly tightening one side of the goggles after experiencing a leak during his or her swim. In most cases, symptoms abate after use of the offending goggles is discontinued. However, with chronic compression of the supraorbital nerve, permanent nerve damage may result.

Signs and Symptoms

Swimmer’s headache is usually unilateral and involves the skin and scalp subserved by the supraorbital nerve ( Fig. 5.2 ). Swimmer’s headache usually manifests as cutaneous sensitivity above the affected supraorbital nerve that radiates into the ipsilateral forehead and scalp. This sensitivity may progress to unpleasant dysesthesias and allodynia, and the patient often complains that his or her hair hurts. With prolonged compression of the supraorbital nerve, a “woody” or anesthetized feeling of the supraorbital region and forehead may occur. Physical examination may reveal allodynia in the distribution of the compressed supraorbital nerve or, rarely, anesthesia. An occasional patient may present with edema of the eyelid resulting from compression of the soft tissues by the tight goggles. Rarely, purpura may be present, secondary to damage to the fragile blood vessels in the loose areolar tissue of the eyelid.

Testing

No specific test exists for swimmer’s headache. Testing is aimed primarily at identifying an occult pathologic process or other diseases that may mimic swimmer’s headache (see “ Differential Diagnosis ”). All patients with the recent onset of headache thought to be swimmer’s headache should undergo magnetic resonance imaging (MRI) of the brain, and strong consideration should be given to obtaining computed tomography (CT) scanning of the sinuses, with special attention to the frontal sinuses, given the frequency of sinusitis in swimmers. Screening laboratory tests consisting of a complete blood count, erythrocyte sedimentation rate, and automated blood chemistry should be performed if the diagnosis of swimmer’s headache is in question.

Differential Diagnosis

Swimmer’s headache is usually diagnosed on clinical grounds by obtaining a targeted headache history. Despite their obvious differences, swimmer’s headache is often misdiagnosed as migraine headache. Such misdiagnosis leads to illogical treatment plans and poor control of headache symptoms. Table 5.1 distinguishes swimmer’s headache from migraine headache and should aid the clinician in making the correct diagnosis.

TABLE 5.1

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