Introduction

Nearly all individuals are affected by headaches of some type during their lifetime. Most of these headaches are very transient in nature and do not significantly impact a person’s ability to function or concentrate. Many are associated with stress or illness and resolve when the underlying condition is corrected. Over-the-counter medications are usually effective in eliminating the symptoms of these inconvenient headaches.

Some headaches are much more significant from both a functional perspective and from an aeromedical certification perspective. They can be temporarily incapacitating and adversely affect the ability to safely operate an aircraft or perform controlling duties. The most common headache of this nature is the "migraine" type. As noted below, there is not one typical "migraine" headache, but rather a variety of symptom complexes all categorized as "migraine" headaches. An excellent article discussing various types of non-disease related headaches written by the FDA adds insight to this complex phenomenon. Another helpful article is found in American Family Physician, Feb. 15, 2001 titled Evaluation of Acute Headaches in Adults.

Rarely, a headache may be the symptom of a much more serious, and potentially life threatening, condition. Immediate evaluation and treatment may be required to prevent permanent neurologic damage or death. The negative aeromedical implications of these conditions are obviously, though not necessarily, permanently disqualifying.

Severe or frequent headaches and their medical treatment is reportable on the FAA Form 8500-8, Airman’s Medical Application, in question 18a. Pilots and controllers should be careful not to characterize an isolated "bad" headache as a migraine headache, because of the certification implications. An article in the Winter 1999 Federal Air Surgeon's Medical Bulletin warns about self-diagnosis of various medical conditions. A casual annotation of an incorrect diagnosis on the Form 8500-8 may lead to loss of certification and a lengthy, expensive evaluation process to regain a medical certificate.

Tension – Muscle Contraction Headaches

Nearly every person has experienced several episodes of tension-type headaches, as they are the most common type of headache experienced. Nearly 90% of headaches not related to disease are the tension-type. Sometimes termed "extra-cranial" because the source of the discomfort is outside of the skull, these headaches are thought to be the result of contraction of the muscles of the face, scalp and neck.

Tension headaches are characterized by soreness or aching that is non-specific in location. Usually the discomfort is bilateral, or on both sides of the head and neck. Neck soreness, a band like pressure around the head, or an aching in the temples are often described. Frequently, individuals will gain some relief by massaging the sore muscles. Although muscle contraction headaches may be very severe, they are not to be confused with, or described as, "migraine headaches."

There are numerous causes of muscle contraction/tension headaches. Illnesses that cause muscle soreness, such as the flu or other viral conditions, frequently cause contraction headaches that may be relieved by over-the-counter medications such as aspirin, Tylenol or Ibuprofen.

Other causes may include personal stress, anger, fatigue, eyestrain, or dehydration. Although medications are often successful in relieving these headaches, avoidance of the cause is the key to prevention. Often, rest, fluids and relaxation will eliminate the pain. A full description of tension headaches is available in the September 1, 2002 issue of American Family Physician in an article, Tension-Type Headache, a patient information handout "Tension Headaches," and an editorial, Editorial: "Tension-Type Headache: A Challenge for Family Physicians"

"Sinus" Headaches

Acute sinus infections may present with pain behind an eye, over the eyebrows or in the upper cheek and teeth. These symptoms may become much more intense when descending rapidly from altitude. Some people have described the intensity as like an ice pick driven through the face. These obviously incapacitating sinus headaches are relieved over time with decongestants, antibiotics and acclimatization to altitude, as well as pain medication. Chronic sinus headaches are not as intense, but require the same treatment to resolve.

FAR 61.53 requires pilots to ground themselves if they have a known medical defect that would compromise the ability to safely operate an aircraft. Acute conditions should be considered grounding, but pilots may legally fly on non-sedating over-the-counter pain relievers such as aspirin, acetaminophen, naproxyn or ibuprofen.

Migraines and Vascular Headaches

In the United States, 4% of women and 1% of men suffer true migraine headaches each year. Nationwide, 12-16 million people suffer from migraine headaches each year. The term "migraine headache" is often used by lay persons to describe a rather severe headache from any cause. This terminology is not accurate and pilots/controllers should be particularly careful in using this term, as it may adversely effect medical certification. True "migraines" may occur without any head pain whatsoever, as noted below.

Migraine headaches are defined as recurrent, benign headaches with or without neurologic symptoms. They are frequently triggered by specific stimuli, such as foods, alcohol, flashing lights, lack of sleep and many others. A key element in the definition is "recurrent". A single typical headache can not be characterized as a migraine unless it recurs. The inclusion of the term "benign" in the definition does not imply that migraines are not severe or incapacitating, but indicates there is no associated medical condition that will progress if left untreated.

Occasionally, an evaluation with CT or MRI scanning is part of the evaluation for migraines. See Practice Guidelines - Headache Consortium Releases Guidelines for Use of CT or MRI in Migraine Work-up from American Family Physician, October 2000. The same journal also has an Evidence Based Medicine review of treatment of migraine headaches from the British Medical Journal.

"Migraine" headaches are also termed "vascular" headaches because the proposed mechanism of the symptoms is spasm and dilation of the blood vessels (vascular) to the brain and its surface. The muscles of the scalp and neck are not directly involved as they are with tension headaches. Treatments to both relieve and prevent of migraine/vascular headaches are designed to alleviate the vascular spasm.

Several types of migraines exist. They are classified by the character of the symptoms. Depending on the symptoms and the frequency, migraine headaches may or may not be disqualifying for flying. The type of treatment and its success is also a major determinant in whether a pilot is authorized to fly with this condition. Some of the various types of migraines are listed below.

Classic Migraine - Migraine with Aura

The classic migraine headache is frequently heralded by a sensory premonition or "aura" before the actual headache. Only about 10% of migraine headaches are accompanied by an aura. The aura may be an unusual smell or taste, flickering lights in an eye, tingling of the face, or other warning. This aura may last seconds to minutes. This is usually followed by an intense headache that may last minutes to days. The headache is often one-sided (unilateral), pounding or throbbing and very distracting, if not incapacitating.

The migraine may be accompanied by nausea and vomiting, sensitivity to light (photophobia) or to noise (hyperacusis). Other symptoms may include loss of vision or speech, confusion, flashing lights, temporary partial paralysis or loss of sensation/feeling. Because of their intensity and associated symptoms that could distract a pilot or controller from full attention to aviation duties, classic migraines that are not preventable are usually disqualifying for medical certification. At times, an avoidable provoking cause may be discovered such as a food (MSG in Chinese food is common), flashing lights, medications, or even intercourse.

Common Migraines - Migraines without Aura

"Common" migraine headaches are nearly identical to classic migraines, but are not accompanied by a warning aura. This type makes up about 75% of migraine headaches. Once the headache manifests, the symptoms are similar in nature, severity and duration to the "classic" migraine. Individuals may have both common and classic migraines, although most tend to have predominantly one or the other. Common migraines are treated the same as classic migraines, although the elimination before the onset of pain is difficult without the aura.

Acephalgic Migraine

"Acephalgic" means "without head pain". Thus an acephalgic migraine is a complex of neurologic symptoms without a headache. About 5% of migraine headaches fall into this category. These episodes may easily be confused with strokes or transient ischemic attacks (TIAs). As with classic or common migraines, symptoms may include partial loss of vision, loss of strength, loss of sensation, difficulty with speech and memory or any other neurologic function. The cause of the symptoms is thought to be spasm of arteries in the brain, thus interrupting blood flow to segments of the brain. These symptoms may be eliminated by the same treatments used for other types of migraines.

Basilar Migraines

Basilar migraines are very similar to acephalgic migraines, but are associated with headaches. They may initially manifest by total blindness, confusion, inability to speak, double vision or vertigo. The confusional states may last from several hours to several days although most symptoms are over in half an hour.

Cluster Headaches

Cluster headaches are a variant of migraines that have a seasonal or periodic nature to their occurrence. Unlike other types of migraines, men are more commonly afflicted than women (8:1 ratio). Cluster headaches comprise about 5% of all migraine type headaches. An individual may be free of any headache symptoms for months or years, and then have a period of time (usually several weeks) when they are afflicted by up to several headaches per day. The headaches are often very intense, associated with eye pain and involuntary tearing. The pain is confined to only one half of the head, usually behind the eye and in the temple. Rather than being throbbing and building over time, they are usually explosive in onset, deep and continuous. Cluster headaches last one to two hours and may occur several times a day, every day for several weeks. Frequently, they may occur at the same time every day.

The treatment of cluster headaches varies from that of other migraines. The usual medication to prevent migraines, beta blockers, do not help. Lithium, a medication usually used for manic-depressive syndromes, seems to be most effective. Sansert is also used for cluster headaches. Alcohol precipitates the majority of initiation of cluster headaches, but not the recurrences.

Jab & Jolt

The "jab and jolt" phenomenon is another variant of vascular headaches. The prime characteristic is a sudden sharp pain followed by a brief (usually less than one minute) of a neurologic deficit (disturbed vision or speech, etc.). Because of the brief duration of the symptoms, treatment is usually focused on prevention rather than elimination of symptoms after onset. Prevention is similar to the techniques used for other migraine type headaches.

Headaches Due to Neurologic Infections

Infections of the Central Nervous System (CNS) are extremely serious, many resulting in lifetime reductions in cognitive abilities or neurologic functions. Most demand immediate treatment to minimize the risk of permanent consequences or death. Infections of the brain itself are termed "encephalitis" and infections of the protective covering of the brain and spinal cord are termed "meningitis."

In general, infections caused by bacteria progress more rapidly, are more often fatal and have more long term complications than viral infections. Bacterial meningitis is treated with antibiotics given intravenously, or even into the fluid filled space around the brain. Viral meningitis often does not require treatment directly against the virus, but only medication to relieve the symptoms. Two exceptions are encephalitis caused by Herpes and HIV, which are treated with antiviral agents.

The major symptoms of a CNS infection headache are an increasingly intense global headache and a stiffness of the neck with forward flexion. Fever, confusion and possibly loss of consciousness often accompany CNS infections.

Because these headaches tend to be isolated events, the primary FAA concern is not a sudden recurrence causing in-flight incapacitation. The concern is whether there are any long term mental or neurologic deficits that could impair judgment or the safe operation in safety sensitive duties such as flying or controlling. Evaluations before returning to flight duties include a comprehensive examination by a neurologist and possibly detailed neuropsychological testing of mental function.

Post-Traumatic Headaches

Headaches may occur for a prolonged period following head trauma. The trauma may seem very minor, and not be associated with loss of consciousness. The headaches may even begin several days after the head trauma. Associated symptoms include fatigue, decreased concentration or mental ability, sleep disturbances, nausea and many other non-specific complaints. This complex is often termed a "post-concussive syndrome." Symptoms may last days, weeks or even months after a relatively minor trauma.

Post-Traumatic Headaches- Non-Penetrating Head Trauma

Concussions

Non-penetrating head trauma may cause three basic types of brain injury. A "concussion" is any brain injury that causes symptoms or disturbances of mental function. Usually, no findings are discovered on CT scans or MIRs of the brain. A classic example is an athlete "getting his bell rung." The U.S. military requires waiting periods from one month to several years before returning pilots suffering these injuries to flying status, depending on the seriousness and duration of symptoms. The FAA does not have a fixed schedule of observation prior to returning pilots to flight following a concussion. Certification decisions made by the FAA depend on the individual factors surrounding the injury, the resolution of symptoms and possibly neurocognitive testing.

Cerebral Contusions

Cerebral contusions are similar to concussions, but there is evidence of bleeding or bruising within the brain tissue. Symptoms are very similar to concussions. An additional concern to the aeromedical community is that blood in the brain is an irritant that places the pilot/controller at increased risk for seizures. The risk decreases over time and with resolution of the blood in the brain. Observation periods following this type of injury before being cleared to return to flight duties are variable, but generally exceed 1-2 years. EEGs are used to monitor abnormal electrical activity of the brain which may lead to seizures.

Intracranial Bleeding

The third type of non-penetrating brain injury involves bleeding into the fluid filled spaces between the brain and the skull. Depending on the space the blood is found, the injury is termed a subdural, epidural or subarachnoid haematoma. The subdural is the most common and least serious, though it can be life threatening. Subdural haematomas may not have any symptoms associated, though a headache, usually dull and diffuse, is the most common symptom. The other two forms of bleeding are immediately life threatening. Symptoms usually include the sudden onset of a severe headache and loss of consciousness. With intracranial bleeding, immediate concerns are the preservation of life, usually with emergency neurosurgical intervention. The FAA will consider waiver requests following such episodes after recovery is complete if there is no increased risk for recurrence. Observation periods of variable lengths are required following intracranial bleeding before the risk of seizure is low enough for favourable consideration of medical certification.

Post-Traumatic Headaches- Penetrating Head Injuries

Any injury that fractures the skull with displacement of the skull fragments inwards is termed "penetrating head trauma." The penetration may be limited to only skull fragments, such as in a blow to the head by a blunt object (ball, bat, etc.) or by striking the head against a fixed object (dashboard, cement, etc.). Penetration with heavy sharp objects (axe, knife, hammer) or high speed projectiles (bullet, arrow, shrapnel) will bring hair, scalp and bone fragments into the wound. This situation is associated with significant brain injuries as well. In both blunt and foreign object penetrating trauma, surgical correction is frequently required as a life saving measure.

For a harrowing perspective involving penetrating head trauma, see the dramatic story of a life-and-death struggle in the cockpit of a Federal Express aircraft during a hijacking attempt by another pilot, Hijacked : The True Story of the Heroes of Flight 705 by Dave Hirschman. The long term consequences of penetrating head trauma are significant from both a medical and an aeromedical perspective. The individual who recovers is at increased risk for seizures for many years. Most individuals have neurologic problems and many will have psychological consequences from their injury.

Increased Intracranial Pressure

A relatively rare cause of headaches is increased pressure within the skull. The pressure increase may arise from fluid collections within the brain that do not properly drain. Both benign and malignant tumors may cause pressure within the skull. The approach to any of these conditions is nearly always surgical.

The FAA policy for reinstatement of medical certificates following surgery for benign tumors (dermoids, meningiomas, adenomas, etc.) requires a minimum one year observation period following surgery. All neurologic functions must return to normal and there must be no increased risk for seizures. Malignant tumors require significantly longer observation periods before any waiver consideration is entertained.

FAA Policy – Treatments for Headaches

Numerous treatments for headaches exist. Correction of the underlying cause of the headache, if possible, is paramount in the treatment and in FAA consideration for medical certificate eligibility. Neurologic function and mental abilities should be normal for the safe operation of an aircraft or performance of controller duties.

FAA Policy – Treatments for Headaches - Non-Migraine Headache Treatment

As mentioned above, tension headaches are usually resolved with time and lifestyle changes. Under the self-assessment of fitness for flight provisions of FAR 61.53, a pilot should control these issues sufficiently before performing flight duties. Use of mild, over-the-counter analgesics (Ibuprofen, Tylenol, aspirin, naproxyn) is permissible during flight duties if there are no side effects. Products with antihistamines and sleep inducing components ("night-time formulas") should not be used. Active hydration during long flights and with mild illnesses may minimize headaches.

FAA Policy – Treatments for Headaches - Migraine Headache Treatment

Medications used to treat vascular type headaches fall into two categories. The first category includes those medications used to eliminate the symptoms once they occur. This category is the "abortant" type medications. The second category is used to prevent headaches from occurring and to decrease the frequency and intensity of those that do. Medicines in this category are called "prophylactic" medications. The New England Journal of Medicine has an excellent review article on "Drug Therapy: Migraine -- Current Understanding and Treatment" in the January 24, 2002 issue.

The FAA policy regarding the use of each category of medication is driven by the overriding concern for the continuous, safe operation in the flying environment. For this reason, abortant type medications are not usually waived if they are the sole treatment for serious vascular headaches.

Abortant Medications

Abortant type medications, such as those containing ergotamines, barbiturates, narcotics, caffeine and analgesics, as well as the newer oral, injectable and nasal inhaled medications take ten minutes to two hours to take effect. They may require a second dose to eliminate symptoms. Sometimes the nausea and vomiting accompanying migraines precludes taking oral medications effectively. Narcotics are sometimes required to relieve severe migraine symptoms. Often nausea is so severe with migraines that intravenous, intranasal or rectal suppository medications are given.

Excellent articles on treatment of migraines in found in American Family Physician titled Practice Guidelines on Migraines Part 2: General Principles of Drug Therapy and Guidelines on Migraines Part 3: Individual Drugs and Management of the Acute Migraine Headache.

Assuming the abortant type medication is effective, the pilot will potentially still have a period of reduced ability to fully concentrate on safe flying while waiting for the medication to take effect. Causes include neurologic symptoms (visual disturbances, impaired speech, temporary weakness), pain which distracts from mental function, or nausea and vomiting. The search for the medication, and the administration of the medications, particularly oral and injectable forms, may be significantly distracting in flight. Occasionally, a "drug rebound" headache will occur after the abortant medication loses effectiveness or is suddenly stopped.

For these reasons, the FAA does not generally certify pilots/controllers relying on abortant medications to treat migraine headaches. The FAA does, however, allow pilots/controllers who are otherwise well controlled on prophylactic medications to carry abortant medications for use in emergency situations in flight or while controlling. This is similar to the frequent practice of pilots carrying Afrin nasal spray as an "emergency-get-me-down" drug in case of a sinus block or ear block. Emergency use of these medications dictates a minimum 24 hour grounding period for a single episode. Recurrent episodes should trigger a re-evaluation of the effectiveness of the prevention program.

In very limited circumstances, the FAA will authorize waivers for pilots or controllers who use abortant type medications, termed "triptans", as a primary means of treating migraine headaches. To meet the criteria, the migraines must not manifest any visual or neurologic symptoms. Additionally, the migraine frequency must be relatively infrequent, approximately less than three per month. Finally, the triptans must be successful in controlling the migraines.

Prophylactic Medications

Preventive, or prophylactic, medications to control vascular headaches are waiverable if successful in preventing migraines and if they are tolerated without significant side effects. The two major classes of medications used, beta blockers and calcium channel blockers, are both used also to control blood pressure and irregular heart rates. Beta blockers include propranolol (Inderal), metoprolol (Lopressor) and others. Calcium channel blockers include diltiazem (Cardizem), verapamil (Calan, Verelan) and others. They must be taken daily to be continuously effective.

Cluster headaches are also treated with Sansert, which can be authorized for use when flying with the FAA. Unfortunately, Sansert can not be used for more than 6 months continuously.

The challenge with certifying pilots/controllers on prophylactic medication is determining if the treatment is effective. There is no set observation period to determine effectiveness. For those who have headaches weekly, several weeks free of headaches after starting medication is probably adequate. Those who only experience headaches several times per year may have to wait a considerably longer period to determine the medication is effective. If migraines are known to be provoked by a specific stimulus (flashing lights, MSG, foods, etc.), an exposure to the stimulus and observation of the reaction may be adequate to demonstrate control of the condition. Sometimes prophylactic medications do not completely eliminate migraines, but decrease the symptoms to tolerable levels, or controllable with allowable medications such as Tylenol or Ibuprofen.

After documentation of control of vascular headaches with prophylactic medications tolerated without significant side effects, documentation can be forwarded to the Aeromedical Certification Division for an eligibility letter. Airmen and controllers should obtain full evaluations and appropriate treatment of all medical conditions to enhance their health and to be fully capable of operating safely in aviation duties.