Electronic ISSN 2287-0237

VOLUME

AIRPLANE HEADACHE

FEBRUARY 2017 - VOL.13 | CASE REPORT

Use of air travel has significantly increased over recent decades. The number of reported airplane-related headache cases has been increasing but this condition remains under-recognized. In this paper, we present a patient with an airplane headache who possesses typical characteristic symptoms during flights and a review of literature.

A 41-year-old, right-handed, Thai lady, who works as a flight attendant, presented to the Neuroscience Center of Bangkok Hospital with a headache. She experienced two episodes of headache during flights, approximately two weeks prior to this hospital visit. The pain was located in the right temporal and right retro-orbital. She described the pain as jabbing or shooting, and was rated 6-8 out of 10 in severity. She denied associated vision changes, photophobia, phonophobia, nausea, vomiting, or trigeminal autonomic symptoms such as nasal congestion, tearing, or conjunctival injection. The pain suddenly occurred shortly after take-off, and persisted throughout the cruising, lasting for a few hours. Her headache eventually subsided after landing. She has taken acetaminophen and mefenamic acid without significant relief. The patient denied any history of prior similar headaches, particularly during previous flights over the past 18 years. She denied any significant past medical history. The patient also denied the history of migraine or tension-type headache. Family history was non-contributory.

On examination, she was alert, awake, and oriented to time, place, and person. Neurological examination was non-focal. There was mild tenderness to palpation of the right temporal head region. No evidence of sinusitis was noted on detailed ENT examination.

She was advised to take naproxen 275 mg approximately an hour prior to air travel. Upon a telephone follow-up, she reported that her symptoms significantly improved after taking the medication, and she denied any treatment side effects. Neuroimaging was not obtained as her symptoms already improved and the patient currently does not experience any headache.

attributed to aeroplane travel as followed:1

A. At least two episodes of headache fulfilling criterion C

B. The patient is travelling by aeroplane

C. Evidence of causation demonstrated by at least two of the following:

1. headache has developed exclusively during aeroplane travel

2. either or both of the following:

a) headache has worsened in temporal relation to ascent after take-off and/or descent prior to landing of the aeroplane

b) headache has spontaneously improved within 30 minutes after the ascent or descent of the aeroplane is completed

3. headache is severe, with at least two of the following three characteristics:

a) unilateral location

b) orbitofrontal location (parietal spread may occur)

c) jabbing or stabbing quality (pulsation may also occur)

D. Not better accounted for by another ICHD-3 diagnosis

Headache related to airplane travel or airplane headache was first reported in 20042, and since then there has been a steady increase in the frequency of reported cases. It had been thought to be a rare form of headache disorder; however, according to a recent online Danish survey, up to 8.3% of the study population meets the diagnostic criteria for airplane headache.3 After formal validation of reported case studies, this category of headache disorder received formal recognition and has been incorporated into the most recent ICHD-3 Beta edition.1

The symptoms of airplane headache patients are highly stereotypic. The most outstanding feature of this condition is its occurrence during airplane travel. Most patients suffer from the headache during the descent of the plane, but the pain can occur during take-off and cruising. The patients typically do not report having headache in situation such as mountain climbing or scuba diving. The headache is usually unilateral, and is typically located in the peri-orbital and frontal zones. Patients usually describe headache as stabbing, jabbing, or sharp. Headache with pulsatile nature has also been reported. The pain usually starts abruptly, reaching maximum intensity within seconds, and subsides within 15-30 minutes. A number of patients report a longer duration of headache lasting for hours. Trigeminal autonomic symptoms such as ptosis, conjunctival injection, ipsilateral tearing, nasal congestion, and nasal discharge can be observed in 24% of patients. Nausea, vomiting, photophobia, phonophobia, or osmophobia, symptoms that are characteristic of migraine, are usually not seen. Most of the patients are male with a mean age of between 20 to 40 years old.4 Coexistence of primary headache disorders such as tension-type headache or migraine has been defined in many patients with airplane headache; the characteristics of which are typically distinct from the headache experienced during flights.5

The etiology and pathogenesis of airplane headache remains unclear. Berilgen and Müngen hypothesize that the abrupt change in cabin pressure during flights can create sinus barotrauma, causing headache in susceptible individuals. In addition, decreased oxygen saturation and a low rate of humidity resulting in dryness in the eyes and mucous membrane may also play an important part in generating headache symptoms. The fact that hypoxia and mucosal dryness generally reach the highest level towards the end of the flight and disappear after landing may explain why headaches frequently occur during descent and rapidly subside spontaneously.4

Airplane headache can be easily treated with simple analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen or ibuprofen, administered before airplane travel.4 Nasal decongestants and antihistamine have been shown to be helpful in some patients.6 Triptans can also be used safely.7 Given the benign nature of this disorder, the use of prophylactic medication may not be necessary.8

Airplane headache has recently been recognized and incorporated into the ICHD-3 Beta edition. This condition “might not be all that rare but just rarely reported.”6 Recognition of its typical characteristics can provide the diagnosis. Patients can be treated with simple analgesics and NSAIDs with good success.