A new type of headache,headache associated with airplane travel: Preliminary diagnostic criteria and possible mechanisms of aetiopathogenesis

Abstract

Background: In recent years, there has been an increase in the reports indicating a form of headache that occurs during commercial aircraft travel. This headache, called airplane headache by some authors, is believed to be a new type of headache. The headache has very specific characteristics and all of the cases exhibited very stereotypical symptoms.

Methods: The headache starts suddenly during the ascent and/or descent of the commercial aircraft. It has a mean duration of 20 minutes, which is usually unilateral and commonly localized to periorbital region. The headache is described to be severe, and has a stabbing or jabbing nature, and generally subsides in a short time. In some cases, an organic cause can be identified whereas in others no organic pathology could be found.

Results and conclusion: We described the clinical features of 22 cases who suffered from a headache that occurred during airplane travel. We examined other cases with similar features reported in the literature and proposed preliminary diagnostic criteria for this new form of headache. We also discussed the possible patholophysiological mechanisms that may cause this headache.

Keywords

Airplane travel headache

Introduction

The first case reported suffering from headache attacks during airplane travel was a 28-year-old male patient reported in 2004 (1). In the following years, there were increasing numbers of patients reported in literature with this type of headache (2–9). The most prominent characteristics of this headache were its occurrence during airplane travel and having specific features. The symptoms of the patients were highly stereotypic. The headache characteristics were not compatible with any other primary headache disorder, including migraine or any trigeminal autonomic cephalalgia.

We analysed all cases with headache associated with airplane travel who presented to our outpatient clinic and the other cases reported in the literature. We defined the characteristics of patients with headaches associated with airplane travel and determined their examination findings as well as radiological analysis. We examined the patients in two different groups. In the first group we found an underlying organic disease (polypoid mass in the frontal sinus, ethmoid sinus osteoma with pneumatocele, chronic rhinosinusitis, etc.) that could lead to or explain the headache (10–13). In the second group, there were no laboratory and radiological abnormality explaining the aetiology of the headache during flight (1–9). In this group, none of the patients had any organic pathology that could cause this headache. Thus, in the present study we examined the second group of patients and excluded the cases with an underlying pathology.

We diagnosed 22 cases who presented to the headache unit of our outpatient clinic or who were referred there from other centres as headache associated with airplane travel. In our patients, there were no laboratory and radiological abnormality. A thorough literature search with extensive evaluation of the cases with strict criteria revealed an additional 11 cases in the literature whose headaches were associated with airplane travel and had no laboratory and radiological abnormalities (1,3–9). Considering all these 33 cases with a specific type of headache, we believe that the headache is caused by airplane travel which may be defined as a new form of headache.

Cases

The characteristics of the headaches that afflicted 33 cases can be listed as follows: Most of the cases were males (28 M, 5 F). Mean age of the patients was 33.12 ± 8.20 years. The headache generally occurred suddenly during the descent of the plane. It occasionally occurred during take off and also when the plane was descending and/or during the flight. The headache was usually unilateral and it was generally localized to periorbital and frontal areas. Quality of the headache was often defined as jabbing, stabbing, and sharp. Some patients felt as if their eyes would pop out. Headaches with a pulsating nature were also reported. Pain started abruptly, reached maximum severity very quickly (in seconds) and spontaneously subsided in 15–30 minutes. A small number of patients suffered from a 30-minute severe pain, which then became moderate and lasted for hours or days. The headache was defined as severe or extremely severe in most of the cases. Mean visual severity scale was measured as 9.22 ± 0.75. Autonomic symptoms like ipsilateral tearing, conjunctival injection, ptosis, nasal congestion, and nasal discharge were observed in eight out of 33 cases (24%) of the patients. There were no signs like nausea, vomiting, photophobia, phonophobia, or osmophobia in any of the patients. One patient described a typical sensorial aura before the headache (8).

Systemic examinations of our 22 patients were conducted by an internal medicine specialist, ear-nose-throat examinations by an ENT specialist, and neurological examinations by a neurologist. Results of all these examinations were found normal. Furthermore, cranial magnetic resonance, magnetic resonance angiography, and paranasal sinus tomography of the patients were evaluated as normal. Examination findings and radiological results of the 11 cases in the literature were also reported as normal. One patient in our series had been receiving sodium valproate 1000 mg/day for epilepsy for the last 4 years, one patient had been receiving 30 mg/day gliclazide for diabetes mellitus for 3 years, and one patient had a history of using salmeterol/fluticasone inhalation disk due to asthma for 6 months. One patient had a cold a month before the flight. Of the patients, eight had been smoking a pack of cigarettes a day for the last 10 years. Nine patients had been consuming alcohol, which was described as drinking one or two glasses of wine, every evening for an average period of 7 years.

All patients having previous attacks of headache-associated airplane travel were examined thoroughly in our clinic. After differential diagnosis and excluding all other aetiological factors the diagnosis of headache associated with airplane travel was accomplished and these patients were recommended to take medication in their subsequent flights. They were prescribed naproxen sodium (550 mg), which is an anti-inflammatory and analgesic agent, to prevent the headache attacks associated with airplane travel. Patients were suggested to take one tablet 1 hour before take off. With this treatment, no headache occurred in 21 (95%) patients and only one (5%) patient had partial relief due to drug treatment.

Table 1.

Demographic and clinical features of the patients

Publication	Case no	Sex	Age	Time onset of airplane headache (years)	Occurring in each flight	Localization of headache	Quality of pain	Intensity of pain	Durations of pain (minute)	When the headache occurs in flight	Accompanying symptoms of headache	Pre-existing diseases in history	History of other primary headaches	Total no. of headaches
Berilgen and Müngen (2006) (2)	1	M	42	2	No	Right eye	Jabbing	Severe	15–20	Landing	No	No	No	4
	2	M	40	1.5	No	Left eye and left supraorbital area	Jabbing	Severe	15	Taking off	No	No	No	3
	3	M	33	7 months	No	Right eye	Jabbing	Severe	15–20	Landing	No	No	Migraine without aura	2
	4	M	36	3	No	Right supraorbital	Jabbing	Severe	15	Landing	Stuffiness on the face and nasal congestion (right side)	No	Exercise headache	3
	5	M	37	4	No	Right eye and right periorbital area	Stabbing	Severe	15–20	Landing	No	No	No	4
	6	M	36	1	No	Right periorbital area and right side of face	Jabbing	Severe	15	Landing	No	No	Retinal migraine	4
Berilgen and Müngen (new cases)	7	F	40	1	No	Right side of forehead	Stabbing	Severe	15–20 min. severe attack; mild headache remained for 3 days	Landing	No	No	No	3
	8	M	34	1	No	Right eye	Sharply	Severe	15–20 min. severe attack in right eye; 3 hours heaviness in right side of forehead	Landing	No	Epilepsy	No	3
	9	M	25	3	Yes	Forehead, around right eye and eyebrow	Badly	Severe	15 min. severe attack; mild headache remained for 1–2 hours in forehead	Landing	No	No	No	Many
	10	M	30	3	No	All of head	An overwhelming feeling that my head will explode (explosive)	Very severe	15	Landing	Slight runny nose and a teary eye (right side)	No	No	3
	11	M	27	2	No	Right eye and right side of forehead	Stabbing	Severe	15	Landing	No	No	No	5
	12	M	33	10 months	No	Above Right eye	Stabbing	Severe	25–30	Landing	Tearing, bloodshot eye ipsilateral	cold	No	2
	13	M	28	3 months	No	Right eye and right side of face	Jabbing	Severe	30–40	Landing	Tearing ipsilateral	No	No	2
	14	M	40	3	No	Right eye	Jabbing	Severe	10–15	Landing	Tearing ipsilateral	No	no	2
	15	M	28	6	No	Around Right eye	Stabbing	Severe	10	Landing	No	No	No	6
	16	M	35	4	No	Left eye and left side of forehead	Feeling that my head will explode	Severe	15–20	landing	No	No	No	3
	17	M	21	2	Yes	Both of temples or all of head	Feeling that my head will explode	Severe	15–20	Landing	No	No	No	Many
	18	M	40	3	No	Left eye	Stabbing	Severe	20	Landing	Tearing ipsilateral	Diabetes mellitus	No	6
	19	M	31	3	Once in every two flights	Middle forehead	sharply	Severe	15	Landing and take off	No	Asthma	No	8
	20	F	39	3	No	Over the left eye	Sharply	Severe	10	Landing	No	No	No	3
	21	M	50	5	No	Forehead, above the eyes	Jabbing (as if one eye was going to pop out)	Severe	15–30	Landing	No	No	No	2
	22	M	47	2	No	Over the right eye	Jabbing	Severe	15–20	Landing	No	No	No	4
Atkinson and Lee (2004) (1)	23	M	28	8	Yes	Forehead, between eyes	Sharp, jabbing	Severe	20	Landing and take off	No	No	No	Many
Mainardi et al. (2007) (4)	24	M	23	1	Yes	Right periorbital, frontal	Pulsating	Very severe	10–15	60–90 minutes after taking off	Tearing ipsilateral	No	No	6
Evans et al. (2007) (3)	25	M	22	2	No	Left temple	Shooting, bursting	Very severe	Very severe 25 minutes, mild pain 30 minutes	Landing	No	Seasonal allergy	Migraine	3
	26	F	23	ND	ND	On the vertex, both parietal regions	Stabbing	Severe	15	Landing	Blurred vision	Brief presyncopal attacks	No	1
	27	F	32	14 months	Yes	Right parietal	Pressure	Mild–severe	6–8 hours	Landing	Noise sensitivity, blurred vision	No	No	Many
	28	M	26	ND	ND	Left periorbital	Piercing	Severe	25–30	Landing	Tearing ipsilateral	No	No	1
Marchioretto et al. (2008) (5)	29	M	ND	ND	ND	Right periorbital	Sharply	Severe	15–20	Landing	Tearing, conjunctival injection and ptosis	ND	ND	2
Kim et al. (2008) (6)	30	M	38	15	During about 80% of flights	Right supraorbital area	Sharp and jabbing	Severe	30	Landing	No	No	No	Many
Coutinho and Pereira-Monteiro (2008) (7)	31	M	57	ND	Yes	Left frontal	Bee-sting	Severe	15–30	Landing	No	No	No	Many
Baldacci et al. (2009) (8)	32	F	20	1	No	Right retro-orbital, frontal	Pulsating	Very severe	20	Take off	Aura with cheiro-oral disturbed sensory disturbances	No	No	3
Domitrz (2010) (9)	33	M	29	ND	No	Left eye and frontal region	Jabbing	Very severe	ND	Take off, cruising, and landing	No	No	No	2

F, female; M, male; ND, not described.

The demographic and clinical features of patients were presented in Table 1.

Discussion

In the present study, we examined the characteristics and clinical features of 33 cases suffering from recurrent headache during airplane travel. We believe that this headache is a new form of headache associated with a specific situation. The symptoms in all patients were highly stereotypic. No organic lesion was detected in any of the patients that could explain these headaches.

In addition, the patients were asked whether they experienced this type of headache in other situations. None of the patients suffered from this type of headache in any other situation (like mountain climbing, scuba-diving, etc.). We believe that ‘headache associated with airplane travel’ may be included in the group of secondary headache disorders according to the International Classification of Headache Disorders.

Considering the current clinical features we can define preliminary diagnostic criteria for headache associated with airplane travel as follows:

At least two severe headaches fulfilling criteria B–C.

Exclusively during airplane travel, together with: Headache with a sudden and severe onset Spontaneous decrease in the severe pain when the ascent and/or descent of the airplane are complete (<30 minutes)

Not attributed to another disorder

The aetiology and pathophysiology of the headache associated with airplane travel remains unclear. The changes that occur in the sinuses and nasal mucosa during airplane travel may be playing a role in triggering the headache. It has already been reported that alterations of cabin pressure, oxygen saturation, air quality, and humidity might cause negative effects on the passengers and cabin crew (14,15). Cabin pressure may change suddenly during the ascent and descent of the plane. It was reported that this rapid change in cabin pressure affects the organs which have air cavities like sinuses and ears (10–13). Additionally, several factors may contribute to sinuses to be acting as closed air cavities (narrow frontal sinus outlet, the narrowness of the openings that ventilate the anterior ethmoid cells, etc.) (16). There may also be variations in these anatomic structures among different individuals either genetically or coincidentally. The pressure within the sinus in which an obstruction is present will have a lower pressure relative to the cabin pressure during descent/ascent of an airplane and this causes a vacuum effect which is referred to as ‘the squeeze’/‘reverse squeeze’ (12,13). This vacuum effect has been reported to be experienced at varying degrees (17,18). The mildest form of changes may cause a temporary discomfort in the sinuses, which results in the strain of the sinus’ mucosal line (18). This effect may be followed by development of inflammation, oedema, and/or serosanguineous exudates at this site. As such changes in the sinus mucosa recover rapidly, nose examinations conducted later on may not reveal any abnormality (17,18).

Several components of the cabin air circulation during the flight can further have negative effects on passengers. Decreased oxygen saturation and the rate of humidity were reported to be the most important factors among these changes (14,15). Alterations in these factors may cause hypoxia and hypercapnia in affected passengers throughout the flight. At the same time, it was reported that low rate of humidity in planes can cause partial dryness in the eyes, mucous membranes, and skin of the passengers (19,20). The sensory innervations of the areas of the sinuses and nasal mucosa are provided by branches of the trigeminal nerve (21). The sensory conduction of ethmoid cells and middle turbinate is ensured by ethmoid and trochlear nerves, which are branches of the trigeminal nerve (21,22). It has been reported that the stimulation of these areas resulted in the development of headache in supraorbital and temporal-zygomatic sites (21–23). Since all the above-mentioned changes may affect the sinuses and nasal mucosa, we believe that these changes can trigger the trigeminovascular system, which receives the sensations of these areas, thereby causing a headache. Furthermore, the ethmoid artery has a superficial trace in ethmoid sinuses and has close relations with ethmoid cells (22). The tension of the mucosa of ethmoid cells due to pressure alterations may induce a stimulating effect on nociceptors on the ethmoid artery. We believe that stimulation of these nociceptors may contribute to the emergence of these headaches. However, with the ending of the flight, these triggering mechanisms disappear and subsequently the severe headache of the patients subsides spontaneously and rapidly. In other words, mucosal dryness, hypoxia, and discomfort reach the highest level towards the end of the flight. This may explain why headaches usually occur during descent. The effects of the humidity rate of the cabin air may change between seats at the front and those at the back of the airplane (24). This may cause passengers to be affected to varying extents during the same flight. It may also explain why the headache attack does not occur in all flights. It was reported in the literature that the dryness in the mucosa, eye, and skin of passengers due to the decrease in the humidity rate of the air supplied into the airplane cabin through compressors was inexplicably more common in males (25). This may provide a possible explanation of why airplane headache is more common in men.

After analysis of the clinical findings and possible aetiological factors related to this new type of headache, we proposed that headache associated with airplane travel generally results from the temporary local inflammation caused by hypoxia or dryness in the sinus mucosa or sinus barotrauma. This hypothesis was supported by our treatment findings in these patients. Headache associated with airplane travel did not occur in 95% of the patients in their subsequent flights when they received naproxen sodium (550 mg) 1 hour prior to take off. Similarly, there was also one report in literature stating the benefit in use naproxen sodium in the treatment of headache associated with airplane travel (5). Anti-histaminic, pseudoephedrine, and nasal decongestant spray treatment can be used as alternative treatments in patients for whom naproxen is contraindicated (3).

In the present study, we defined a new type of headache which is purely associated with airplane travel and occurs only during ascent or descent of a plane which might be related to pressure changes. Technological advances that minimize the rapid changes in cabin pressure during the ascent and descent of the airplane may prevent the occurrence of this attack.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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