Brief Communication

An Unusual Case of an Airplane Headache

Victoria Atkinson, MD; Liesly Lee, MSc, MD, FRCPC

A 28-year-old man developed severe headache associated with changes in altitude during ascent and descentwhile flying in an airplane. Jabbing pain over the forehead and between the eyes began within minutes of ascent. Itresolved once a cruising altitude was reached, but then returned at the start of descent.

Key words: headache, altitude, atmospheric pressure, travel, aircraft

(Headache 2004;44:438-439)

Primary headache disorders are common. In astudy of headache in Canada, 14% of adults reportedmigraine and 36% reported tension-type headache,while another 14% reported symptoms fulfilling cri-teria for both forms of headache.1 The Interna-tional Headache Society (IHS) classification includes12 forms of primary headache, each with multiplesubtypes.2

Even so, not all headaches currently reside withinthat classification system. We present a patient withheadache uniquely associated with airplane travel.

CASE HISTORYA 28-year-old man developed severe headache as-

sociated only with airplane travel. He had traveledpreviously by airplane on multiple occasions as a childand adolescent with no difficulties. He had no relevantmedical history and was on no medications. There wasno family history of headache. He denied any symp-toms suggestive of sinus disease.

The first episode occurred in his early 20s while hewas on a transatlantic flight. Within 10 minutes of theplane ascending, the patient noted the dramatic onset

From IWK Health Center, Dalhousie University, Halifax, NovaScotia (Dr. Atkinson) and Sunnybrook and Women’s CollegeHealth Sciences Centre, University of Toronto, Ontario (Dr.Lee); Canada.

Address all correspondence to Dr. Liesly Lee, Sunnybrook andWomen’s College Health Sciences Centre, A-411, 2075 BayviewAvenue, Toronto, Ontario M4N 3M5, Canada.

Accepted for publication January 4, 2004.

of a severe headache. He described it as a sharp jabbingpain over the forehead and between the eyes. Therewas no photophobia, phonophobia, nausea, or vom-iting. There were no visual disturbances or any otherfocal neurologic symptoms. He denied excessive tear-ing or rhinorrhea. The patient preferred to sit still andnot move. The headaches lasted for about 20 minutes,resolving spontaneously as soon as the plane reached alevel cruising altitude. The identical headache recurredwhen the plane began its descent, only to resolve againwith landing.

This pattern of headache was recurrent with eachflight (generally 1 to 2 per year) over the subsequent8 years. On his most recent flight before assessment,the symptoms were prolonged and lasted throughoutmost of the flight. This changing pattern concernedhim, and brought him to seek medical attention.

Findings on neurologic examination were com-pletely normal. There was no evidence of sinus pathol-ogy. Computerized tomography (CT) of the sinuseswas normal. Brain magnetic resonance imaging (MRI)did not reveal any abnormalities.

DISCUSSIONA review of the medical literature published be-

tween 1966 and April 2003 yielded only one article re-lating headaches to flying.3 A 46-year-old airline cap-tain began to experience headaches with flying afterinitiation of therapy with pravastatin for hypercholes-terolemia. An incapacitating migraine-like pain devel-oped after 30 to 45 minutes of exposure to high alti-tude. The pilot noted that the increases in altitude led

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to increased pain intensity. He was able to alleviatethe headache within minutes by lowering the altitudeof the plane. The headaches occurred only if he tookthe pravastatin.

Our patient was not on any precipitating medica-tions. His headaches were related to changes in alti-tude, rather than altitude per se.

Headaches are a common symptom of acutemountain sickness.4 The IHS has defined a primaryheadache disorder of high-altitude headache (HAH)as one that develops “within 24 hours after sudden as-cent to altitudes above 3000 m,” in association withCheyne-Stokes respiration, desire to overbreathe, orexertional dyspnea.2 A primary mechanism involvingthe cerebral vasculature has been advanced to explainthe phenomenon, with the assumption that the ves-sels are hypersensitive to rapid atmospheric changes.Conceivably, rapid changes in altitudes can induce va-sospastic changes in the cerebral vasculature. In themore extreme cases of acute mountain sickness, anacute encephalopathy with ataxia has been describedand termed high-altitude cerebral edema (HACE);neuroimaging reveals vasogenic cerebral edema.5 In aprospective study by Silber and colleagues, involvingtrekkers in Nepal, over 80% developed at least oneHAH at a mean altitude of 4723 meters. The HAHswere more severe in women, were variable in theirheadache characteristics, and were less common in

older subjects.6 The trigger in HAH is attainment of aspecific altitude. In our case, however, it was the rapidchange in altitude that triggered the headaches, andnot the altitude itself.

Acknowledgment: The authors wish to thank Dr. J.

Edmeads for his thoughtful review of this article.

REFERENCES

1. Pryse-Phillips W, Findlay H, Tugwell P, et al. ACanadian population survey on the clinical, epidemio-logic and societal impact of migraine and tension-typeheadache. Can J Neurol Sci. 1992;19:333-339.

2. Headache Classification Committee of the Interna-tional Headache Society. Classification and diagnos-tic criteria for headache disorders, cranial neural-gias and facial pain. Cephalalgia. 1988;8(suppl 7):1-96.

3. Ramsey CS, Snyder QC. Altitude-induced migraineheadache secondary to pravastatin: case report. AviatSpace Environ Med. 1998;69:603-606.

4. Hackett PH, Roach RC. High altitude illness. N EnglJ Med. 2001;345:107-114.

5. Hackett PH, Yarnell PR, Hill R, et al. High-altitudecerebral edema evaluated with magnetic resonanceimaging: clinical correlation and pathophysiology.JAMA. 1998;280:1920-1925.

6. Silber E, Sonnenberg P, Collier DJ, et al. Clinical fea-tures of headache at altitude: a prospective study. Neu-rology. 2003;60:1167-1171.