I proceed to go through an abbreviated preflight walk around my body. The first stop is my head. Some pretty essential organs and structures sit on my shoulders that need monitoring. If I wake up with a headache, it may change my visual acuity, decision-making, and overall well-being.
Headache is the most common disorder seen in the clinic setting. Headache is the fourth leading cause of emergency room visits. Severe and sudden headaches account for 3.5 million ER visits per year in the United States, with primary headache disorders (migraine, tension-type headache, and trigeminal autonomic cephalalgias) comprising the majority of these visits (Trends in the management of headache disorders in US emergency departments: analysis of 2007-2018 national hospital ambulatory medical care survey data. J Clin Med. Published online March 3, 2022). Migraine headaches affect more than 10% of people worldwide, occur most often among people ages 20 to 50 years, and are about three times more common in women than in men. In an extensive US survey, 17.1% of women and 5.6% of men reported having migraine symptoms (JAMA. 2022;327(1):93).
There are four categories of headaches: tension, hypnic, migraine, and cluster. A tension headache is a hatband headache. The pain of a tension headache is typically felt around the back of the head, the temples, and the forehead. A hypnic headache occurs in people between forty and eighty years of age. The hypnic headache appears at the same time at night, lasts fifteen to sixty minutes, and the pain occurs in all areas of the head. Migraine headaches are the most common headache. It is unilateral, and its duration is between two and seventy-two hours. Migraine patients may have a sensitivity to light, sound, or smell, pulsating pain, nausea/vomiting, symptoms worsened by physical activity, and are seen more often in families. There are two types of migraines: with or without auras (85% of cases). Cluster headaches last between twenty minutes and two hours. A cluster headache is a unilateral (only one side) symptom associated with a stuffy nose, tearing, an enlarged pupil, or droopy lid.
The medication treatments for chronic tension headaches are acetaminophen, ibuprofen, naproxen sodium, and beta blockers. Amitriptyline (antidepressant) and divalproex sodium (anticonvulsant) are sometimes utilized in tension headaches but are not approved therapies by the FAA. Acetaminophen (Tylenol) is a pain reliever that is taken in tension headaches around the clock for pain. The maximum per day dose of acetaminophen is 4,000 mg or 4 grams. This maximum dose is because the body has a buffering system that neutralizes the potentially toxic metabolite as acetaminophen is broken down in the liver. At doses greater than 4 grams, the buffering chemical is exhausted. The toxic metabolite of acetaminophen that has not been neutralized begins to destroy the liver. The maximum dose of ibuprofen (Advil) is 1,200 mg daily, and the maximum dose of naproxen sodium (Aleve) is 600 mg daily. The significant side effects of ibuprofen and naproxen sodium are GI bleeding, retention of sodium and water, and possible renal failure. Beta blockers prescribed for tension headaches include metoprolol tartrate/succinate, and propranolol. The side effects of beta blockers are bradycardia (low heart rate), hypotension (low blood pressure), and heart blocks.
Hypnic headache treatments approved by the FAA include caffeine, melatonin, and indomethacin. It is an interesting concept to use caffeine for a headache that occurs at night. Caffeine at 40 to 60 mg has shown good results in treating hypnic headache. It is also very well tolerated by the elderly and, surprisingly, does not interfere with sleep. Caffeine is used as a first-line treatment for these headaches. The FAA indication for melatonin is insomnia, with a 24-hour wait period before a flight. Indomethacin is an NSAID (nonsteroidal anti-inflammatory drug) that is in the same category as medications like ibuprofen. The renal side effect of indomethacin is significant.
Cluster headache therapy is very similar to treatment for migraine headaches. Cluster headaches are associated with intense pain. A neurologist educated me that his patients describe the pain as worse than passing a kidney stone or more significant than in childbirth. Oxygen is one of the best abortive therapies, with relief seen in as little as 15 minutes. Triptan injections, like sumatriptan (Imitrex), will decrease pain impulses to the brain, lower the release of inflammatory chemicals, and cause vasoconstriction of the blood vessels. Prevention therapy for cluster headaches includes verapamil. Verapamil is a rate-controlling calcium channel blocker medication that can cross the blood-brain barrier. The mechanism of action of verapamil in cluster headaches is not known. The postulated mechanism of action may be the blockage of many different calcium and potassium channels. Verapamil may also work on a human ether-a-go-go-related gene (HERG). HERG always makes me giggle when I attempt to explain the mechanism of verapamil.
Migraine headaches are the most common of the four headache types. A migraine headache pathophysiology is one of vasodilation, mast cells, severe pain that can be debilitating, and in some cases, lasting seventy-two hours. The sensory manifestations of migraines with auras are flickering lights, spots in the visual fields, loss of vision, needle-like feelings, numbness in the hands, and speech problems. A pneumonic I use to remember the symptoms of a migraine is POUND (P - pulsatile, O - one-day duration, U - unilateral, N - nausea/vomiting, and D - disabling).
The triggers of migraines are increased stress, changes in sleep patterns, estrogen changes during menstrual periods, and foods. Monosodium glutamate, smoked fish, cured meats, chocolate, and aged cheeses (Swiss, Parmesan, brie, and cheddar) contain tyramine. It is postulated that high levels of tyramine and norepinephrine may cause migraine headaches.
The goals for acute treatment of migraine headaches are relief of pain, ability to perform daily functions, decreased need for additional acute medications, no adverse drug events, and cost of the migraine treatments. The FAA-approved, guideline-based therapy for migraines includes triptans, NSAIDs (ibuprofen and naproxen sodium), aspirin/acetaminophen/caffeine (Excedrin Migraine), and CGRP antagonists. If a migraineur does not have their medications available, I recommend drinking coffee or tea. Black tea has the highest amount of caffeine per cup. The triptans affect three serotonin receptors in the brain. Two serotonin receptors, if blocked by triptans, decrease pain and stop pain signaling. One serotonin receptor will block the vasodilation of brain vessels caused by the migraine headache. Side effects of the triptans are chest pain, heart attack, hypertension, and cold extremities. Triptans are manufactured as tablets (dissolvable), nasal sprays, and injections. If relief is not seen, a second triptan dose can be given two hours after the last dose. Examples of triptans are sumatriptan (Imitrex), zolmitriptan (Zomig), eletriptan (Relpax), rizatriptan (Maxalt), almotriptan (Axert), frovatriptan (Frova), and naratriptan (Amerge). A 24-hour wait period before flying after the last dose is required for triptan use, except for Relpax, which has a 72-hour wait period.
The newest class of anti-migraine medications are CGRP antagonists. Calcitonin-gene-related peptides (CGRP) are proteins found in the nervous system and are responsible for processing pain, increasing inflammation, and contributing to the development of migraine attacks. CGRP antagonists are prescribed when the triptans are not providing relief for the migraine headache. Examples of CGRP antagonists are ubrogepant (Ulbrelvy), fremanezumab-aooe (Ajovy), galcanezumab-gnim (Emgality), Rimegepant (Nurtec ODT), and atogepant (Qulipta). Side effects include back pain, visual problems, and tingling sensations. There is a 36-hour wait period before flying for Ulbrelvy and a three-day observation period after the first dose of Nurtec ODT.
Preventive therapy is prescribed for patients with more than four headaches a month or headache days of eight a month. Prophylactic treatment is instituted to decrease migraine rates and severity. The largest category of preventive medications is beta blockers. Propranolol extended release has over sixty studies showing benefits. Metoprolol has four randomized controlled trials showing benefits to prevent migraines.
For issuance of a medical certificate with a migraine diagnosis, please refer to the Migraine and
Chronic Headache Worksheet FAA guidelines. The FAA guidelines are very specific in the requirements for a medical certificate.
Migraine headache or any severe headache can cause disabling effects in the cockpit. Headaches rank among the top five reasons for emergency room visits and the top 20 reasons for outpatient visits (Headache. 2013;53(3):427-436). The severity and duration of a headache are important criteria for appropriate treatment. Recognition and common sense are your friends in the headache world. Listen to your inner voice. Do not fly, and treat your headache appropriately. Frequent headaches are a reason to make an appointment with your healthcare provider sooner rather than later. Fly safe and be well.
