Migraine after training: prevention, diagnosis and when to see a doctor

If a headache after training has become a regular pattern, it can and should be controlled. Some attacks respond to prevention through simple changes in routine, some require a doctor, and certain types of pain are a signal of dangerous conditions. Our editorial team has prepared a practical overview: what to do before and after training, how the diagnosis is made, and which symptoms require emergency care.

Prevention: how people with migraine should train

Regular aerobic activity can reduce the frequency of attacks, so giving up sport is not the answer. The task is to remove those elements of training that provoke pain and keep those that help.

The most important element is the warm-up. A gradual increase in heart rate over 10–15 minutes lets the vessels and nervous system adapt, whereas an abrupt start at maximal intensity is one of the most frequently mentioned triggers. In strength training it is worth avoiding prolonged straining with breath-holding, especially at the start of a session.

1. Schedule workouts at the same time of day if possible.
2. Warm up gradually, do not start with maximal effort.
3. Increase volume and intensity gradually, without sharp jumps.
4. Avoid training in intense heat without adaptation.
5. Add a cool-down and do not switch abruptly from intense work to complete rest.

Sleep is another key factor. Both sleep deprivation and excessive sleep on weekends can provoke attacks. For athletes with early training sessions this means careful planning of bedtime.

It is also useful to work with pre-start stress. Migraine attacks often occur not at the moment of stress but after it — on the rest day following a competition. Relaxation techniques, breathing exercises and a gradual reduction of activity after a start reduce this risk.

Nutrition, fluids and caffeine

Regular meals are one of the simplest ways to prevent attacks. Fasted training, long gaps between meals and low-carbohydrate diets increase the risk of attacks in susceptible people. Before training, a meal with carbohydrates is advisable, and afterward, the replenishment of glycogen stores.

Hydration should be adequate but not excessive. It is best to be guided by thirst, urine color and the change in body weight before and after training, and during prolonged exertion in the heat — to use drinks with electrolytes.

Caffeine requires special attention. Steady moderate intake usually does no harm, but large doses from several sources — coffee, energy drinks, pre-workout complexes — and abrupt withdrawal before competitions or on weekends can provoke headaches. If you need to reduce caffeine, do it gradually.

Supplements for migraine prevention that neurological guidelines consider are magnesium, riboflavin (vitamin B2) and coenzyme Q10. The evidence base for them is moderate; their use should be discussed with a doctor, especially if you are already taking other agents.

Diagnosis: what the doctor assesses

The diagnosis of migraine and primary exercise headache is made clinically according to the criteria of the International Classification of Headache Disorders (ICHD-3). The doctor asks about the nature, location and duration of the pain, accompanying symptoms, the presence of aura, the frequency of attacks, medication use and the connection with training.

The best aid in diagnosis is a headache diary: the date and time of the attack, the type of training, the conditions, nutrition, sleep, caffeine, supplements, painkillers taken and their effectiveness. After a few weeks such records often reveal clear patterns.

Additional examinations for typical migraine are usually not needed. However, for headache related to exertion, especially at the first episode, doctors more often order neuroimaging (MRI or CT, sometimes with a vascular study) to rule out subarachnoid hemorrhage, an aneurysm, arterial dissection, a tumor or a malformation. Blood pressure is also checked.

For athletes it is important to tell the doctor about all supplements, stimulants and hormonal drugs, and the frequency of painkiller use. Blood pressure, hematocrit and caffeine load may be directly related to the headache.

Treatment: general principles and sports-specific nuances

Treatment of migraine is divided into stopping an attack and preventive therapy. To stop an attack, simple painkillers and NSAIDs are used, and for moderate and severe attacks — triptans; newer classes of drugs targeting CGRP are used as indicated. The choice of drug and the dose are determined by a doctor.

The key rule is not to overuse painkillers. Frequent use (on average more than 10–15 days a month depending on the class of agent) risks the development of medication-overuse headache, when the drugs themselves sustain the chronic pain.

Preventive therapy is considered when attacks are frequent or severe. For athletes the choice of drug has its particularities: beta-blockers can reduce maximal aerobic performance and are banned by WADA in certain sports; topiramate can affect body weight and cognitive function and increase the risk of kidney stones; amitriptyline can cause drowsiness. So the doctor and athlete together weigh the benefit against the impact on training.

For athletes who compete under doping control, any prescription should be checked against the current WADA Prohibited List, and if necessary a therapeutic use exemption should be obtained before starting treatment.

When to see a doctor

A neurologist is recommended for anyone whose post-training headache recurs, worsens or forces them to give up their sessions. You should also see a doctor if you need painkillers more often than a few times a month.

Some signs require emergency care. They correspond to the "red flags" of secondary headache, summarized in the SNNOOP10 list (Do et al., 2019):

• sudden, "thunderclap" pain that reaches its maximum within seconds to a minute;
• the first-ever severe headache during exertion;
• pain with fever, neck stiffness, a rash;
• pain with weakness in the limbs or disturbances of speech, vision or consciousness;
• pain after a head injury;
• pain that first appeared after age 50, or a sharp change in the usual character of the pain.

A separate situation is headache together with a sharp rise in blood pressure, chest pain, shortness of breath or heart-rhythm disturbances. This may be a sign of a hypertensive crisis, especially against a background of stimulants or hormonal drugs, and requires immediate medical care.

You should also not ignore a headache combined with confusion and nausea during a long start in the heat: this is how heatstroke or hyponatremia can manifest.

Editorial conclusions

Migraine after training can be controlled in most cases: a warm-up, gradual progression of loads, regular meals, hydration, stable sleep and a sensible attitude to caffeine reduce the frequency of attacks.

The diagnosis is made clinically, and a headache diary is the best tool for finding triggers. A first episode of pain during exertion often requires neuroimaging to rule out secondary causes.

Thunderclap pain, neurological symptoms, fever with neck stiffness, or pain after an injury are reasons to seek help immediately.

We also recommend reading our articles on the causes of migraine after training and the role of pharmacology, on caffeine in sport, and on training in the heat.

References

1. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211.
2. Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019;92(3):134–144.
3. Eigenbrodt AK, Ashina H, Khan S, et al. Diagnosis and management of migraine in ten steps. Nat Rev Neurol. 2021;17(8):501–514.
4. Varkey E, Cider A, Carlsson J, Linde M. Exercise as migraine prophylaxis: a randomized study using relaxation and topiramate as controls. Cephalalgia. 2011;31(14):1428–1438.
5. Diener HC, Dodick D, Evers S, et al. Pathophysiology, prevention, and treatment of medication overuse headache. Lancet Neurol. 2019;18(9):891–902.
6. Ashina M. Migraine. N Engl J Med. 2020;383(19):1866–1876.
7. World Anti-Doping Agency. The World Anti-Doping Code: International Standard. Prohibited List. Montreal: WADA; чинна редакція.