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|Year : 2013 | Volume
| Issue : 2 | Page : 164-166
Headache associated with airplane travel: A rare entity
Ajith Cherian1, Mini Mathew2, Thomas Iype1, P Sandeep1, Afshan Jabeen3, K Ayyappan1
1 Department of Neurology, Government Medical College, Trivandrum, Kerala, India
2 Senior Consultant in Ophthalmology, Rose Eye Clinic, Vellayambalam, Trivandrum, Kerala, India
3 Department of Neurology, Nizams Institute of Medical Sciences, Hyderabad, India
|Date of Submission||08-Jan-2013|
|Date of Decision||11-Feb-2013|
|Date of Acceptance||12-Mar-2013|
|Date of Web Publication||29-Apr-2013|
Department of Neurology, Government Medical College, Trivandrum, Kerala
Source of Support: None, Conflict of Interest: None
Airplane travel headache is rare and has recently been described as a new form of headache associated with a specific situation. Of the 1,208 patients with primary headaches attending a tertiary care neurology hospital, two (0.16%) patients satisfied the criteria for headache related to airplane travel. Both the patients fulfilled the proposed diagnostic criteria for airplane travel headache. This unique headache had a mean duration of 24 minutes, localized to the medial supraorbital region described as having an intense jabbing or stabbing character that occurred exclusively and maximally during aircraft landing or take-off, following which pain intensity subsided . This rare headache felt on aircraft descent is probably due to the squeeze effect on the frontal sinus wall, when air trapped inside it contracts producing a negative pressure leading to mucosal edema, transudation and intense pain. Use of nasal decongestants either alone or in combination with naproxen sodium prior to ascent and descent abated the headache episodes. Awareness about this unique entity is essential to provide proper treatment and avoid patient suffering.
Keywords: Airplane travel Headache, barosinusitis, frontal sinus, nasal decongestants, naproxen sodium, sinus barotrauma, sinus squeeze
|How to cite this article:|
Cherian A, Mathew M, Iype T, Sandeep P, Jabeen A, Ayyappan K. Headache associated with airplane travel: A rare entity. Neurol India 2013;61:164-6
| » Introduction|| |
Headache associated with airplane travel was first reported in 2004.  Since then there have been several case reports. ,,,,,,, The fact that so few cases have been reported to date despite two billion people traveling by air every year indicates either the rarity of this entity or lack of awareness among medical practitioners. The most prominent characteristics of this headache include: Headache exclusively occurring during airplane travel, short duration, severe in intensity, and medial supraorbital location. The diagnostic criteria of airplane travel associated headache include:  (A) at least two severe headaches fulfilling criteria B-C; (B) headache exclusively during airplane travel, with a sudden and severe onset and spontaneous decrease in the pain severity when the ascent and/or descent of the airplane is complete (duration < 30 minutes); and (C) not attributed to another disorder.
The symptoms of these patients are highly stereotyped and the headache characteristics are not compatible with any other primary headache disorder, including migraine or trigeminal autonomic cephalalgia. We report two such patients.
| » Case Report|| |
Case records of all the patients with headache presenting to a tertiary care neurology center in south India were analyzed. Of the 1,208 primary headaches seen in one year, two patients satisfied the criteria for headache associated with airplane travel [Table 1]. Both patients had neuroimaging including magnetic resonance imaging (MRI) of the brain and computed tomography (CT) of paranasal sinuses.
|Table 1: Clinical features of the patients with headache related to airplane travel|
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Both the patients were young male (34 and 32 years of age) medical professionals and had symptom onset two years prior to attending the clinic when their professional commitments necessitated air travel. Mostly the headache onset was sudden during the descent of the plane and the intensity used to gradually wean once the aircraft reached a height of 500 feet above the ground. It used to completely abate by the time they checked out of the airport. It occasionally used to occur during takeoff also. The headache was mostly unilateral, localized to the medial supraorbital region spreading on occasions to ipsilateral frontal areas. Description of the quality of headache was "jabbing", "stabbing", and "sharp". Both felt as if their eyes would pop out due to the excruciating nature of headache which curtailed their air travel. Pain used to start abruptly, reaching maximum severity quickly within minutes and used to subside spontaneously in <30 minutes. On visual analogue scale the mean severity was 9.5. Mild conjunctival injection was reported by one patient. Neither of them reported any nausea, vomiting, photophobia, phonophobia, or osmophobia. One patient described fullness over the forehead before the headache. In both of them brain MRI and CT of the paranasal sinuses were normal. One patient had a history of migraine without aura but was not on any prophylaxis as he had infrequent migrainous headaches. None had any history of substance abuse and both were teetotallers. The patients were asked regarding their experience of similar type of headaches in other situations. Mountain climbing did not elicit a similar headache while they had never gone for scuba-diving.
Based on the above clinical and investigative data a diagnosis of "headache associated with airplane travel" was made and patients were recommended to take oxymetazoline nasal drops prior to takeoff and landing. With this treatment intensity of headache was reduced by approximately 85-90% in both of them. Combination therapy with addition of naproxen sodium (500 mg) totally abolished the headaches. Patients were advised to take the tablet 30 minutes prior to takeoff and nasal drops shortly after being seated in the aircraft. Drops might be repeated few minutes prior to aircraft descend in a prolonged flight.
| » Discussion|| |
The symptoms of both the patients were highly stereotyped and the headache characteristics meet the criteria for airplane travel headache.  Headache associated with airplane travel has been included in the group of secondary headache disorders according to the International Classification of Headache Disorders.
The postulated pathophysiology of the airplane travel headache is based on the Boyle's law, which states that the volume of a gas is inversely proportional to the pressure on it, when temperature is constant (P1 × V1 = P2 × V2). Headaches in patients with airplane travel headache are due to the acute barotrauma affecting most commonly the frontal sinuses. Possible explanations for this might be the relatively long and delicate nasofrontal duct that connects the narrow frontal recess with the frontal sinuses and this narrow outlet makes it susceptible to sudden pressure changes. Normally the sinuses drain into the nasal cavity through small ostia, which permit mucociliary clearance and ventilation, that equilibrates pressure. However, when the opening is obstructed due to inflammation, polyps, mucosal thickening or due to anatomical abnormalities, pressure equilibration is impossible. During ascent, the air in the paranasal sinuses will expand according to Boyle's law and contract during descent producing a "squeeze effect". On descent this negative pressure differentials are directed towards the center of the sinuses producing mucosal edema, transudation, mucosal-or submucosal-hematoma, leading to further occlusion of the sinus ostium. The sinuses will fill with fluid or blood unless the pressure differentials are neutralized.  Barotrauma in the maxillary, ethmoidal, or sphenoid sinuses is observed less frequently and appear only when the ostia are blocked due to an upper respiratory tract infection. If the outlet is blocked during ascent, the situation is reversed and "reverse squeeze" occurs.  Pressure inside the sinus increases, producing pain or epistaxis. Narrow frontal sinus outlet, the narrowness of the openings that ventilate the anterior ethmoid cells may contribute to sinuses acting as closed air cavities.  Variations in these anatomic structures among different individuals may also be a factor. As such changes in the sinus mucosa recover rapidly nasal examinations conducted later may not reveal any abnormality.  The sensory innervations from the areas of the sinuses and nasal mucosa are provided by branches of the trigeminal nerve.  These changes can trigger the trigeminovascular system, which receives sensations from these areas, thus causing a headache. The ethmoidal artery has close relation with ethmoidal cells. The tension of the mucosa of ethmoidal cells due to pressure alterations may induce a stimulating effect on nociceptors on the ethmoidal artery. Stimulation of these nociceptors may also contribute to the genesis of these headaches. The mucosal dryness that occurs in conditioned cabins in an aircraft may add to the discomfort.  However, as the flight touches the ground, pressure difference between the sinus and atmospheric slowly equate and subsequently the headache intensity subsides spontaneously and rapidly. The headache attack may be less severe or even absent in larger aircrafts while it tends to be severe in smaller congested flights. Anatomical variations like narrower frontal ostia are more common in males and this may provide a possible explanation, why airplane travel headache is more common in men.
Magnitude of pressure difference needed to produce barotrauma shows great individual variation and is related to the size of the sinus ostium and the rate of ambient pressure change. Most of the airplane travel associated headaches are observed in high performance military aircrafts with lower pressurized cabins. In the military setting, in-flight management of acute sinus barotrauma typically involves ascending to a level which makes the pilot asymptomatic and administration of a nasal decongestant.  After resolution of the pain, a slow descent usually prevents further symptoms. However, this may not be possible in a commercial flight. Headaches associated with airplane travel reduced by 85-90% in both the patients during the subsequent air travels with the use of oxymetazoline nasal drops prior to ascend and descend of flight. Addition of naproxen sodium half an hour prior to takeoff completely abated the symptoms. There is documented evidence for the beneficial effects of naproxen sodium in the treatment of headaches associated with airplane travel.  Pseudoephedrine containing nasal decongestants are an alternative in patients in whom naproxen is contraindicated.  These two patients emphasize the importance of recognizing this unique type of headache. Early recognition and institution of appropriate treatment helps to avoid patient suffering.
| » Conclusion|| |
Awareness about this new form of headache associated with airplane travel is essential to provide proper treatment and avoid patient suffering. Barotrauma producing a "squeeze" or "reverse squeeze" effect in the frontal sinuses over the medial supraorbital region may explain this phenomenon. Use of nasal decongestants either alone or in combination with naproxen sodium prior to ascent and descent of airplane provides symptomatic relief.
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