Airplane Headache II: The Sequel

Airline travel during the holidays is one big headache. But for some people, “airplane headache” is a truly painful experience. The headache occurs during take-off and landing, is unique to plane travel, and is not associated with other conditions. The pain is severe, with a jabbing or stabbing quality, and located on one side of the head (usually around the eye sockets or forehead).

Airplane headache was initially described as a rare event in the medical literature. In fact, a 2004 report called it An unusual case of an airplane headache (Atkinson & Lee, 2004):

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

Six years later, another case report noted how rare it is (Domitrz, 2010):

Headache with normal examinations and imaging, occurring during an airplane flight has been rarely reported. We present a young patient with a new type of headache that appeared during flights: take-off and landing of a plane and was not associated with other conditions. This airplane headache is rather rare in population and the pathophysiology of this type is not clear.

This claim is contradicted by 240 miserable passengers who commented on The Neurocritic's 2010 post, which appeared soon after that paper was published. Granted, the comments have accumulated over six years, but they clearly show that it's not an unusual occurrence.

Now, a new Danish survey reveals that up to 8.3% of the respondents suffer from airplane headaches (Bui et al., 2016). The online survey was publicized through the Facebook pages of Scandinavian airlines and related organizations.¹ The survey consisted of 14 questions. The first six asked about demographic information, including nationality, age, gender, migraine and history of high altitude headache (HAH). The other questions asked about symptoms, co-occurring medical conditions, and type of flight.

The survey participants were 254 Scandinavian air travelers. Among those, 89 (35%) said they suffer from headaches attributed to airplane travel. However, only 21 (8.3%) met the International Headache Society's diagnostic criteria for airplane headache (e.g., headache lasts less than 30 min, is not due to sinus congestion, etc.).²

The authors defined two groups: the AH group (n = 21; 12 female, 9 male) and the non-AH group (n = 233). The mean age of the AH group was 39 ± 14 years (range 19–67 yrs).

The majority of AH participants (91%) described their headache as unilateral, fronto-orbital or fronto-parietal. The headache was described mainly as “pressing” (43%), but also pulsating (29%) and stabbing (29%). The intensity of headache was described as severe (57%) or moderate (43%).

When asked to provide a possible cause for their headache, changes in cabin pressure during take-off and landing was reported as the most possible cause of their AH (95%).

The AH group was further divided into two subgroups: A medicated-group (n = 5) and a non-medicated-group (n = 16). One person took paracetamol (acetaminophen) and four used triptan drugs (used to treat migraines and cluster headaches). An earlier paper found that triptans may be effective in preventing airplane headaches (Ipekdal et al., 2011).

One caveat of the present study is that the respondents were self-selected: they visited the Facebook pages of airlines and were (probably) more inclined to complete the survey if they suffer from airplane headaches.

What causes airplane headaches? One idea is that reversible cerebral vasoconstriction syndrome (RCVS) could be involved in some cases of AH (Hiraga et al., 2016). The most prominent hypothesis suggests that barotrauma is involved, with pressure changes affecting the trigeminovascular system (Berilgen & Müngen, 2006). The most comprehensive explanation of sinus barotrauma comes from Mainardi et al. (2012), who discuss “the physical changes in the paranasal sinuses due to the modification of external ambient pressure according to Boyle’s Law.” 

But why is it that relatively few people experience this excruciating pain during ascent and/or descent? Mainardi et al. (2012) again:

...the most likely AH physiopathology seems to be related to a variety of multimodal contributing factors: anatomic factors, such as acquired or congenital abnormalities of sinus outlet, environmental factors (cabin pressure, aircraft speed, angle of ascent/descent, maximum altitude), concurrent factors that act by reducing the sinus ventilation, such as a temporary mucosal oedema, possibly worsened, in predisposed individuals...

Airplane Headache: The Discussion

If you suffer from airplane headaches I encourage you to visit my earlier post, and to read the comments, and to share your own experiences.


Footnotes

¹ Participants reached the questionnaire through a link that took them to Google Docs. The survey was open from October 15, 2014 to December 1, 2014.

² I've pasted in the list of diagnostic criteria in its entirety at the bottom of the post.


References

Atkinson V, Lee L. (2004). An unusual case of an airplane headache. Headache 44:438–439

Berilgen MS, Müngen B. (2006). Headache associated with airplane travel: report of six cases. Cephalalgia 26:707-11.

Bui, S., Petersen, T., Poulsen, J., & Gazerani, P. (2016). Headaches attributed to airplane travel: a Danish survey The Journal of Headache and Pain, 17 (1). DOI: 10.1186/s10194-016-0628-7.

Domitrz I. (2010). Airplane headache: a further case report of a young man. J Headache Pain 11:531-2.

Hiraga A, Aotsuka Y, Koide K, Kuwabara S. (2016). Reversible cerebral vasoconstriction syndrome precipitated by airplane descent: Case report. Cephalalgia Aug 12. [Epub ahead of print].

Ipekdal HI, Karadaş Ö, Öz O, Ulaş ÜH. (2011). Can triptans safely be used for airplane headache? Neurol Sci. 32:1165-9.

Mainardi F, Lisotto C, Maggioni F, Zanchin G. (2012). Headache attributed to airplane travel ('airplane headache'): clinical profile based on a large case series. Cephalalgia 32(8):592-9.


10.1.2 Headache attributed to aeroplane travel

Headache Classification Committee of the International Headache Society (IHS). (2013). The International Classification of Headache Disorders, 3rd edition (beta version) Cephalalgia, 33 (9), 629-808. DOI: 10.1177/0333102413485658

Description:

Headache, often severe, usually unilateral and periocular and without autonomic symptoms, occurring during and caused by aeroplane travel. It remits after landing.

Diagnostic criteria:

    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.

Comments:

10.1.2 Headache attributed to aeroplane travel occurs during landing in more than 85% of patients. Side-shift between different flights occurs in around 10% of cases. Nasal congestion, a stuffy feeling of the face or tearing may occur ipsilaterally, but these have been described in fewer than 5% of cases.

The presence of a sinus disorder should be excluded.