Primary Exertional Headache - The Basics

by Teri Robert Patient Advocate

Primary exertional headache (PEH) is a headache brought on by exercise, any form of exercise and is experienced by approximately 10% of the population. It is more common among men than women.

PEH is termed "primary" because it's not caused by another condition or disorder.

PEH is more likely to occur in hot weather or at high altitude, but it can occur in any weather and at any altitude. PEH is more likely to occur if alcohol or caffeine have been consumed prior to or during exercise.

The pain of PEH usually (but not always) comes on suddenly, can be unilateral or bilateral (on both sides of the head), and is often pulsatile. PEH generally lasts from five minutes to 48 hours, and the headache may be accompanied by:

PEH is often self-limiting, which means that it occurs for a period of time, then stops occurring. PEH is often self-limiting to a period of three to six months.

When diagnosing PEH, it is essential that imaging studies be performed to rule out subarachnoid hemorrhage and arterial dissection. Lumbar puncture may also be indicated to rule out issues related to the cerebrospinal fluid and / or cerebrospinal fluid pressure.

Prevention and treatment of PEH:

In cases where the headache is mild or builds slowly, warming up before exercising and / or an exercise program that begins slowly and increases in intensity and length over a period of months may prevent PEH.

Naproxen taken before exercise may prevent PEH in some cases. If participating in exercise more frequently than two or three days per week, care should be taken to avoid medication overuse headache.

Beta blockers (propranolol, timolol, etc.), given in doses similar to those for Migraine prevention have been shown to be effective in preventing PEH. Indomethacin at a dosage of 25-250 mg daily has also been effective in some cases. However, with indomethacin, treatment should be monitored to avoid stomach irritation and / or medication overuse headache. Since PEH is self-limiting, it's suggested that beta blockers be discontinued after six months for reevaluation of the need for the treatment.

The International Headache Society classification criteria

The IHS classification and description of primary exertional headache is as follows:

4.3 Primary exertional headache

Previously used terms: Benign exertional headache

Coded elsewhere: Exercise-induced migraine is coded under 1. Migraine according to its subtype.

Description: Headache precipitated by any form of exercise. Subforms such as "weight-lifters' headache" are recognised.

Diagnostic criteria:

  1. Pulsating headache fulfilling criteria B and C

  2. Lasting from 5 minutes to 48 hours

  3. Brought on by and occurring only during or after physical exertion

  4. Not attributed to another disorder1

Note: 1 On first occurrence of this headache type it is mandatory to exclude subarachnoid haemorrhage and arterial dissection.

Comments: Primary exertional headache occurs particularly in hot weather or at high altitude. There are reports of prevention in some patients by the ingestion of ergotamine tartrate. Indomethacin has been found effective in the majority of the cases.

Headache described in weight-lifters has been considered a subform of 4.3 Primary exertional headache; because of its sudden onset and presumed mechanism it may have more similarities to 4.2 Primary cough headache.

Summary and comments:

Primary exertion headache occurs only during or after physical exertion. If exercise brings on a headache for you, it's important to see your doctor so more dangerous issues such as subarachnoid hemorrhage and arterial dissection can be ruled out. The good news is that PEH tends to be self-limiting and stops occurring after three to six months. A change in exercise regimen or treatment can help prevent PEH.

It is important to note that primary exertional headache is not the same as a Migraine triggered by exertion.


The International Headache Society. "International Classification of Headache Disorders, 2nd Edition." Cephalalgia, Volume 24 Issue s1. May, 2004. doi:10.1111/j.1468-2982.2003.00823.x.

Silberstein, Stephen D.; Lipton, Richard B.; Dodick, David W. "Wolff's Headache and Other Head Pain, eighth edition." Oxford University Press. 2008.

Silberstein, Stephen D.; Lipton, Richard B.; Goadsby, Peter J.; Smith, Robert F. "Headache in Primary Care." Isis Medical Media. 1999.

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Teri Robert
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Teri Robert

Teri Robert is a leading patient educator and advocate and the author of Living Well with Migraine Disease and Headaches. A co-founder of the Alliance for Headache Disorders Advocacy and the American Headache and Migraine Association, she received the National Headache Foundation's Patient Partners Award and a Distinguished Service Award from the American Headache Society.