BRIEF REPORT

Space headache: a new secondary headache

AA Vein

, H Koppen

, J Haan

1,3

, GM Terwindt

& MD Ferrari

Department of Neurology, Leiden University Medical Centre, Leiden,

Haga Hospital, The Haque, and

Rijnland Hospital, Leiderdorp,the Netherlands

Vein AA, Koppen H, Haan J, Terwindt GM & Ferrari MD. Space headache: a newsecondary headache. Cephalalgia 2009; 29:683–686. London. ISSN 0333-1024Headache is a common, but rarely voiced, complaint during space flights,usually attributed to space motion sickness (SMS). We used a specificallydesigned questionnaire based on the criteria of the International Classification ofHeadache Disorders, 2nd edn (ICHD-II). Of the 16 male and one femaleastronauts who participated in the survey, 12 (71%) reported having experiencedat least one headache episode while in space, whereas they had not suffered fromheadache when on earth. There were in total 21 space headache episodes, ofmoderate to severe intensity in 71%. In two astronauts (12%) the headache andassociated symptoms would match the ICHD-II criteria for migraine and in three(18%) astronauts for tension-type headache; in 12 (70%) astronauts the headachewas non-specific. The vast majority of headache episodes (76%) were notassociated with symptoms of SMS. We conclude that space flights may triggerheadaches without other SMS symptoms in otherwise ‘super-healthy’ malesubjects. We propose to classify space headache as a separate entity among thesecondary headaches attributed to disorders of homeostasis.

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Headache, microgravity, astronauts Alla A Vein MD, PhD, Department of Neurology, Leiden University Medical Centre,PO Box 9600, 2300 RC Leiden, the Netherlands. E-mail: a.a.vein@lumc.nl Received13 May 2008, accepted 2 September 2008

Introduction

Headache is a common complaint, primarily occur-ring in women (1). There are many putative triggerfactors for migraine and other episodic headaches,including nitric oxide, alcohol, hormonal fluctua-tions, (relaxation after) stress, exercise, fatigue,sudden drop in barometric pressure, and acutechanges in sleep or food-intake pattern (2). Travel inspace is a less well-known trigger, although thereare anecdotal reports of disabling headache duringspace flights. These headaches are usually consid-ered to be part of the space motion sickness syn-drome (SMS) (3–5). Detailed clinical descriptions ofheadache during space flights, and its relation toSMS, are lacking. Establishing space flight as aspecific trigger for headache in otherwise ‘super-healthy’ non-headache subjects would help a betterunderstanding of the mechanisms leading toheadache. By contacting the astronauts, who repliedon a voluntary basis, we sought to assess the preva-lence and clinical characteristics of headache andassociated symptoms during the various phases ofspace missions. A specifically designed question-naire was used that was based on the criteria of theInternational Classification of Headache Disorders,2nd edn (ICHD-II) (6). The majority of astronautswho participated reported having experienced dis-abling headaches while in space, but not on earth.

Subjects and methods

Between October 2006 and April 2008, a randomselection of 17 astronauts (16 male, one female;mean age 41 years; range 28–58 years) completed aspeciﬁcally designed headache questionnaire thatwas based on the ICHD-II (6). If headache wasreported, its characteristics and accompanying

doi:10.1111/j.1468-2982.2008.01775.x

683© Blackwell Publishing Ltd

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, 2009,

, 683–686

symptoms were questioned in a yes/no fashion.Four specific time frames of the space flight weredefined: launch (period between the launch ofspace vehicle and docking to the space station), stayat the space station, activity outside the spacestation [extravehicular activity (EVA)] and landing(between undocking from the space station andlanding). The presence or absence of headache ‘onearth’ was also assessed. The descriptive clinicalapproach was used for data analysis. Informedconsent was deemed unnecessary as none of thequestions addressed sensitive topics. All subjectsparticipated on a voluntary basis.

Results

All astronauts had passed special and very detailedmedical examinations before space ﬂight and areconsidered as healthy subjects. Nine astronauts hadparticipated in short-duration space missions (up to2 weeks; mean 10.9 days; range 8–14 days) andeight in long-duration missions (mean 201.7 days;range 150–366 days). Twelve of the 17 astronauts(71%) reported one or more episodes of headacheduring the space mission. There was no differencein occurrence of headache between astronauts onshort- and long-duration missions. The 12 astro-nauts with headache reported a total of 21 headacheepisodes: nine during launch, nine during the stayat the space station, one during EVA and twoduring the landing (Table 1). Five astronauts hadheadache during one of the time frames, six duringtwo time frames and one during all four timeframes. The latter was the only one who experi-enced headache during EVA. Headache severityranged from mild to severe, with mild intensity in29% and moderate to severe intensity in 71%, butwas usually reported as moderate (65%). This ishow one of the astronauts described the headache:‘S

o here I was with a Big Headache. I pressed my headagainst one of the cargo bags to help with my Headache.I rolled up in my sleeping bag with my head pushedagainst the cargo and spent most of the day sleeping

’.Sixty-four per cent of the astronauts took analgesicsfor their headache. Two of the individual headacheepisodes (both during launch) matched the ICHD-II

Table 1

Characteristics of headache episodes during space mission (

21)Launch Stay at the space station Landing EVANumber % Number % Number % Number %Astronauts with headache 9 53 9 53 2 12 1 6Mean headache duration (min) 336 – 98 15 – 15 –SeverityMild 1 11 4 45 0 0 1 6Moderate 7 78 5 56 2 100 0 0Severe 1 11 0 0 0 0 0 0Increasing with physical exercise 3 33 2 22 0 0 0 0Increasing with stress 0 0 3 33 0 0 0 0CharacterUnilateral 1 11 3 33 1 50 0 0Pulsating 1 11 3 33 1 50 0 0Pressing 2 22 1 11 0 0 0 0Stabbing 0 0 0 0 0 0 0 0Monotone 4 45 5 56 1 50 0 0Exploding 4 45 2 22 0 0 1 6Heavy feeling 7 75 5 56 1 50 1 6Accompanying symptomsNausea 4 44 1 11 0 0 0 0Vomiting 2 22 0 0 0 0 0 0Photophobia 1 11 1 11 0 0 1 6Phonophobia 0 0 0 0 0 0 0 0Osmophobia 0 0 0 0 0 0 0 0Vertigo 3 33 1 11 1 50 0 0Sleeplessness 3 33 3 33 0 0 0 0Visual complaints 2 22 1 11 0 0 0 0Nasal congestion 6 67 6 67 1 50 0 0

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, 683–686

criteria for a migraine attack. The remaining head-ache episodes were tension-type or non-speciﬁc(Fig. 1). In 77% of the episodes, headache wasdescribed as ‘exploding’ and/or ‘a heavy feeling’: by eight out of nine astronauts during the launch, by seven out of nine during the stay at the spacestation, by one astronaut during the EVA and bytwo out of two during the landing. When eachindependent headache episode was assessed, 16(76%) demonstrated no association with the mainsymptoms of SMS, such as nausea, vomiting orvertigo. None of the astronauts had a history ofrecurrent headache on earth.

Discussion

Although headache in space is generally considerednot to be a major issue, our study has demonstratedthat disabling headache frequently occurs duringspace missions in subjects who otherwise do notsuffer from headache while on earth. This is inaccordance with previous studies (7–9). As astro-nauts are known to be reluctant to reveal all physi-cal complaints (10), the true headache incidencecould be even higher than reported here.The majority of the astronauts experienced head-ache episodes of moderate intensity, which in manycases required the use of analgesics. Althoughheadache during space flights is usually attributedto SMS (5, 9–12), most astronauts who reportedheadache did not experience associated SMS symp-toms. The generally held view that headache is justa symptom of SMS could thus not be confirmed.Most headache episodes did not fulfil theICHD-II criteria for one of the primary headachetypes. Two headache episodes fulfilled the criteriafor a migraine attack that include nausea, vomitingand photo- and phonophobia. As these symptomsmay sometimes also be part of the motion sicknesssyndrome, it is difficult to establish the true natureof these symptoms by using only a questionnaire.Occurrence of the headache only under specificconditions of microgravity would classify it as asecondary headache. To describe headache, mostastronauts used terms such as ‘exploding’ and/or ‘aheavy feeling’, confirming previous observationsand suggesting a change in intracranial pressure(13, 14). This is compatible with headache attrib-uted to disorders of homeostasis [G44.882] (6),which can change during a state of microgravity (5,15). Certain haemodynamic changes might explainthe occurrence of space headache. Alteration ofcerebral blood flow and volume have been shownduring exposure to microgravity (12, 16). The moststriking change is the cephalad fluid shift, when body fluid redistributes and the blood volume inthe upper body increases (17, 18). The fluid shifttowards the brain and probable brain oedema couldlead to an increase in intracranial pressure (9, 16,19). Insofar as microgravity is also known to inducehypoxia, it also might be considered as a plausibletrigger for space headache (20).We conclude that space headache is a commonand often isolated, disabling complaint duringspace flight. It should be classified as a separateentity among the secondary headaches attributed todisorders of homeostasis.

References

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