By Louise M. Klebanoff, MD

Assistant Professor of Clinical Neurology, Weill Cornell Medical College

Dr. Klebanoff reports no financial relationships relevant to this field of study.

SYNOPSIS: Severe, unilateral headaches that occur during airplane travel, particularly during landing, are most likely a variant of migraine headaches triggered by changes in cabin pressure.

SOURCE: Mainardi F, Maggioni F, Volta GD, et al. Prevalence of headache attributed to aeroplane travel in headache outpatient populations: An Italian multicentric survey. Cephalalgia 2019;39:1219-1225.

Headache attributed to airplane travel (AH) has been described in patients with primary headache disorders during air travel. In the third edition of the International Classification of Headache Disorders (ICHD-3 beta), AH is listed among other forms of headache attributed to disorders of homeostasis. AHs are described as severe, incapacitating, unilateral headaches lasting 30-45 minutes and occurring during air travel. The incidence of AH among air travelers with previously diagnosed primary headache disorders is unknown. Mainardi et al sought to evaluate the prevalence of AH in a sample of patients referred to one of six Italian headache centers. The authors reviewed the data of 869 consecutive patients referred to outpatient headache centers for an initial evaluation of headache; none presented with a chief complaint of AH. The authors excluded 136 patients because they had never flown. Of the remaining 733, 34 reported headaches during air travel. Four reported headaches meeting ICHD-3 beta criteria for migraine without aura and were excluded from the analysis. Of the 30 patients remaining, 24 were referred to the clinic for migraine without aura, four for tension-type headaches, and two for a combination of migraine without aura and tension-type headaches. The age of presentation to the clinic was 36.4 ± 9.5 years, with the first flight occurring at a mean age of 16.7 ± 4.8 years. AH did not occur with the first flight; the mean age of AH onset was 28.4 ± 5.9 years. There was a preponderance of men (18 of 30 patients). Although patients often attribute AH to sinus disease, none of the 30 subjects reported inflammatory sinus disease concomitant with the AH attacks.

All patients reported AH occurred during landing; one patient also reported symptoms during takeoff. In one patient, AH lasted for 45 minutes. In the others, AH lasted for less than 15 minutes (10 subjects) or between 15 and 30 minutes (19 patients). A milder headache, lasting up to 24 hours, persisted in four patients. The pain intensity was very severe or unbearable in all patients, with a mean score of 9.6 on a 10-point visual severity score. The quality of pain was described as stabbing (22 patients) or jabbing (eight patients). The pain always was unilateral, fronto-orbital (23 patients), or frontoparietal (seven patients). The same side usually was affected with recurrent attacks; in five patients, subsequent attacks were contralateral. Recurrent attacks were variable. Five subjects reported AH on all flights; six in more than 75% of flights, 14 in more than 50% of flights, and five on occasional flights. Restlessness was reported in five patients, two had accompanying ipsilateral conjunctival injection and tearing, and one had both restlessness and vegetative signs; these accompanying symptoms could mimic cluster headache. Ninety percent of subjects reported the occurrence of AH negatively affected their propensity for future flights, with concomitant anxiety frequently reported prior to and during air travel.

Ten patients tried pharmacological interventions, such as simple analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs), either alone or in combination with a decongestant nasal spray, with 50-75% efficacy reported. Nasal decongestants alone were not effective. Maximum efficacy was achieved when the medications were taken 30-60 minutes before the anticipated AH attack. A patient with episodic migraine headaches and frequent AH found taking a long-acting triptan prior to air travel eliminated AH attacks in 75% of subsequent flights. In several patients, AH-like attacks also were triggered by free snorkeling or scuba diving (diving ascent headache) or rapid descent from high altitude (mountain descent headache), leading to the hypothesis that these headaches may be triggered by an imbalance between the intrasinusal and external air pressure, which in turn could cause mechanical activation of the nociceptors of the ethmoidal artery and the trigeminovascular system. This proposed pathogenic mechanism explains why AH may respond to triptan medications.

COMMENTARY

Mainardi et al found the prevalence of AH to be 4% in an adult outpatient population referred to a headache center for other primary headache disorders. In all cases, the headaches occurred during landing; were unilateral, very severe, stabbing, or jabbing; and lasted for 15-45 minutes. Approximately 25% of patients reported restlessness and less frequent ipsilateral conjunctival injection and tearing. Despite the severity of AH, no one reported AH as their presenting complaint, and only one-third resorted to pharmacological interventions. Taking a nasal decongestant spray and a simple analgesic or NSAID 30 minutes before the anticipated AH attack reduced AH by 50-75% in subsequent flights. AH is a not-infrequent, severe headache syndrome seen in patients with other primary headache disorders and likely is preventable with simple interventions. Improved awareness of this condition is needed among headache patients and providers. Additional research is needed to prospectively collect and assess treatment interventions, including analgesics with or without nasal decongestants and triptans.