Test Your Clinical Skills

Test Your Clinical Skills

Case Summary:

30 year old male

Ethnic background: Caucasian/White

Symptoms began: 13 years 8 months ago

Current medications:
Almotriptan 1 time other for Taken as migraine abortive
Body systems affected:
Head or neck (Primary Body Area Affected)
Symptoms detail:
I’ve been getting migraines for the majority of my adult life, starting around age 17 (I’m 30 now). Migraine symptoms are usually limited only to head pain (typically concentrating around the forehead/eyes, could be either left or right side, not consistently one side). If the migraine is severe enough, I’ll get nauseous as well. I do experience auras from time to time but they’re rarely directly correlated to an oncoming migraine.

I’ve played hockey ever since I was five years old, usually several days a week, and this has never caused me any issue with my migraines previously, but all of a sudden starting three years ago, I get a migraine almost every single time I play. This issue isn’t limited only to playing hockey but seems to apply to almost all other forms of exercise as well. Typically anything that would be considered more than a ‘light’ workout will trigger this pain with me. It seems to me that if there’s any intense cardiovascular activity within a workout (long run or sometimes even short run, intense sports, crossfit workout), then I will almost definitely suffer a migraine afterwards.

Luckily, these are typically aborted fairly effectively when I take my migraine abortives (almotriptan, in this case), but given that I’m fairly active and am playing hockey and other sports many times in week, this can result in my need to take these medications fairly often, and then I end up in a cycle of rebound headaches.

These migraines typically don’t occur during or right after I exercise but rather tend to set in slowly and hit full-force within about 1.5-4 hours after. It begins as a form of tension centralized around my forehead and eyes that becomes progressively more intense until I’m hit with strong pain and sometimes nausea as well. Even if the exercise is at night and I go to bed shortly afterwards, these become strong enough to wake me from my sleep.

I’ve been told (by my GP, neurologist and chiropractor/sports physio) that this is most likely related to the muscles in my neck-shoulders becoming tense while I exercise, but none of their suggested solutions have helped so far, including:

-Taking ibuprofen + naproxen before exercise
-Frequent neck and shoulder stretches before, during and after
-Was prescribed propranolol as a migraine preventative which worked great for about four months before not working any more, plus made me feel very sluggish and low enery when exercising.
-Quit caffeine
-Tried taking magnesium and vitamin B2 supplements
-Acupuncture
-Massages

My typical routine to try and prevent these migraines is as follows, as has ~25% success rate. So, not very effective and is also extremely excessive especially for something like a 25 minute run:

PRE-EXERCISE
-Tons of hydrating. Drink lots of water and/or sports drinks.
-Try to eat a decent meal 1-2 hours beforehand
-Stretching
-400mg Ibuprofen
-Use a lacrosse ball to massage pressure points in my shoulders

DURING
-Lots of neck and shoulder exercised
-Use a lacrosse ball to massage pressure points in my shoulders
-Hydration

POST-EXERCISE
-Hot-shower immediately after
-Use a lacrosse ball to massage pressure points in my shoulders
-Lots of stretching
-Apply RUB-A535 to forehead, neck, shoulders to tide me over until I get home
-Once home I use an electric massager on my neck and shoulders for 20-40 mins
-Hot compress over my forehead/eyes

Again, this only rarely works for me and takes a lot of time and effort to apply.

My suspicion is that this maybe goes beyond simple muscle tension causing headaches/migraine after sports, given that the main trigger seems to be an intense cardio workout, but alas the reason I’m here is because I really can’t seem to get a definite answer for what is causing this and how best to prevent it.

Current medications:
Almotriptan 1 time other for Taken as migraine abortive
Problems with specific body parts or systems:
Head or neck (Primary Body Area Affected)
Personal medical history:
Hernia operation @ age 5

Experiencing migraines since ~17 years old

Fairly intense seasonal allergies (hayfever, congestion, watery eyes) at most times of year.

Daily stomach pains experienced near daily about one year ago. Endoscopy performed with nothing found but slight inflammation of esophagus.

Family medical history:
All four grandparents died of heart-related issues (heart attacks and strokes)

Mother and sister both get migraines but not from exercise.

Secondary or partial diagnoses:
Tension headaches caused by muscle exertion

Personal struggle:
To be honest, I’d love to write at-length about my struggle with migraines in general and how they’ve affected my overall enjoyment of life, but my triggers tend to vary, and I’m at a point where I’m able to manage them relatively effectively EXCEPT for when it comes to exercise.

Exercise and sports are a huge part of my life, and I’m at a point where I’m almost having to sit out most physical activities because of the guarantee of migraines afterwards. I’m also gaining weight and feel extremely out of shape now that I’m not able to exercise and be as active as I’d like to be.