Is a New Diagnostic Category for Airplane Headache Ready to Fly?

Neurology Today
2 August 2012; Volume 12(15); p 18

Samson, Kurt

Outline

article in brief
more data needed?
references:

ARTICLE IN BRIEF

Investigators report on the symptoms of airplane headache in a new case series of patients.

The short but intense headaches reported by some passengers when flying on airplanes — especially during descent — may be a new category of head pain, according to the latest case series.

There have been anecdotal reports of so-called “airplane headache” (AH) in the medical literature, dating back to 2004, but in the June edition of the journal Cephalalgia, Federico Mainardi, MD, and researchers at the Headache Center in the Neurological Department of the SS Giovanni e Paolo Hospital in Venice, Italy, reported certain common denominators in these patients, suggesting a unique symptomatic signature.

After Dr. Mainardi reported the first case of AH in Italy in 2007, a number of individuals with similar symptoms contacted him. As a result, he was able to collect profiles on 75 patients and, several years ago, proposed a set of diagnostic characteristics.

The new syndrome will be included as a distinct headache category in the third edition of the International Headache Society Classification, according to David Dodick, MD, professor of neurology at the Mayo Clinic in Phoenix, AZ, and president of the American Headache Society, who was not involved with the study.

The headaches tend to last less than 30 minutes in almost all patients, they occur most often in men, and usually when a plane is descending. The pain itself is unilateral and is usually localized to the fronto-orbital or fronto-parietal areas. There are no other signs or symptoms, but the pain is reported to be severe by every subject, and categorized as unbearable by more than 85 percent.

DR. FEDERICO MAINARDI reported the first case of airplane headache in Italy.

[ Click here to enlarge ]

“Airplane headache seems to be a common condition, but we actually have no epidemiological data regarding how widespread it might be,” Dr. Mainardi told Neurology Today in an e-mail.

“Usually, the onset of AH does not coincide with the first flight experience, nor does it happen every time an affected individual flies. People with the condition do not have acute or chronic sinus pathology, so it must be differentiated from an upper-respiratory tract infection, a well-known problem that can cause headaches during air travel,” he noted.

“That the pain appears inconstantly in the majority of cases, without any evident disorder affecting the paranasal sinuses, could be consistent with a multimodal pathogenesis underlying this condition, possibly resulting in the interaction between anatomic, environmental and temporary concurrent factors.”

He suggested that barotrauma might be the main mechanism involved in the pathophysiology of AH in the absence of other pathological disorders.

Dr. Mainardi acknowledged several major limitations to the review of patients included in the series, however. Only three patients underwent physical and neurological examination — the rest responded to questionnaires — and only one-third underwent extensive neuroimaging to rule out other forms of headaches that might be caused by sinus disorders.

He advised that if AH is suspected, organic pathology should first be ruled out, and cerebral MRI and a coronal sinus CT scan should be performed. Importantly, people should be advised that the condition is benign, and that using non-steroidal anti-inflammatory drugs before the expected onset of the pain can help, as can nasal spray decongestants before flights, he told Neurology Today.

MORE DATA NEEDED?

Commenting on the paper, Joel Saper, MD, founder and director of the Michigan Head Pain & Neurological Institute in Ann Arbor, said that while he applauds the work done by Dr. Mainardi and his colleagues, additional research in larger numbers of patients is needed to better define the symptoms and causes.

“One review article does not make a case,” he told Neurology Today in a telephone interview from the American Headache Society's annual meeting in June in Los Angeles.

“This is definitely a phenomenon, but it is hard to know the range of symptoms that make up such cases. For instance, the finding that the condition occurs mostly in men needs clarification. I have heard of many women who have this condition as well.”

The paper's finding that it occurs predominantly upon descent is also questionable, he said, noting that many of his patients report having the headache before an airplane begins its landing process.

“That said, this is a nice study of a series of patients, and identifies vulnerability factors with this phenomenon in certain patients. Nevertheless, that the findings were not consistent among patients raises questions,” he told Neurology Today. Some of them did not get a headache every time they were on a plane that was landing, and this needs further investigation.”

Another interesting finding was that AH was reported in both individuals with and without upper respiratory infections, Dr. Saper noted.

“I think the findings raise more questions than they answer. The authors have done all of us a service by charting this as a potentially separate phenomenon, and with time we will know better just who is vulnerable and, perhaps why. But we are not there yet. We need more studies in larger groups of patients.”

In an accompanying editorial, Allan Purdy, MD, professor of medicine in the Division of Neurology at Dalhousie University/QEII Health Sciences Center in Halifax, Canada, said that even with limitations inherent in studies involving individual cases, it is not unprecedented for case series to provide enough evidence to support adding a new category of headache to the International Headache Society Classification.

Although only a small number of AH cases have been reported in the medical literature to date, and it is difficult to translate case reports into evidence-based practices, he said the findings suggest a unique disorder.

Dr. Dodick agreed, adding: “It has become clear that this is a stereotypically unique form of headache associated with either ascent or descent, and it is not due to sinusitis or any structural sinus lesion.”

Moreover, he said the condition is likely more prevalent than anyone thinks. But because it is so brief, many individuals do not seek any medical help.

With 100 cases documented to date, he believes many more will be reported as word circulates.

“For some people it even scares them from flying. Physicians should be asking patients who travel if they experience this phenomenon, especially if they are prone to headaches anyway.”

He recommends that anyone who has suffered airline headaches to carry ibuprofen or a similar drug with them, instead of using a nasal inhaler, and to use them as a prophylactic measures just before they fly. Some people take stronger drugs, but usually ibuprofen is sufficient, Dr. Dodick commented. “I've heard of some people taking [migraine medication] triptans, but that is probably not a good idea.”