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  • Research article
  • Open Access

Headache attributed to aeroplane travel: the first multicentric survey in a paediatric population affected by primary headaches

  • 1,
  • 1,
  • 2,
  • 1,
  • 3,
  • 4,
  • 5,
  • 6,
  • 7,
  • 8,
  • 9,
  • 1,
  • 1,
  • 2 and
  • 1Email author
Contributed equally
The Journal of Headache and PainOfficial Journal of the "European Headache Federation" and of "Lifting The Burden - The Global Campaign against Headache"201819:108

https://doi.org/10.1186/s10194-018-0939-y

  • Received: 16 September 2018
  • Accepted: 30 October 2018
  • Published:

Abstract

Background

This multicentric survey investigates the prevalence and characteristics of Airplane Headache in children affected by primary headaches.

Methods

Patients with symptoms of Airplane Headache were recruited from nine Italian Pediatric Headache Centres. Each patient was handed a structured questionnaire which met the ICHD-III criteria.

Results

Among 320 children suffering from primary headaches who had flights during their lifetime, 15 (4.7%) had Airplane Headache, with mean age of 12.4 years. Most of the patients were females (80%). The headache was predominantly bilateral (80%) and localized to the frontal area (60%); it was mainly pulsating, and lasted less than 30 min in all cases. Accompanying symptoms were tearing, photophobia, phonophobia in most of the cases (73.3%). More than 30% of patients used medications to treat the attacks, with good results.

Conclusion

Our study shows that Airplane Headache is not a rare disorder in children affected by primary headaches and highlights that its features in children are peculiar and differ from those described in adults. In children Airplane Headache prevails in females, is more often bilateral, has frequently accompanying symptoms and occurs at any time during the flight.

Further studies are needed to confirm the actual frequency of Airplane Headache in the general pediatric population not selected from specialized Headache Centres, with and without other concomitant headache condition, and to better clarify the clinical characteristics, pathophysiology and potential therapies.

Keywords

  • Headache
  • Aeroplane travel
  • Airplane
  • Primary headaches
  • Children
  • Pediatric headache
  • ICHD-III

Background

Headache disorders in children and adolescents are common disabling problems with a significant impact on the quality of life of both children and parents [1, 2].

Airplane headache (AH) is a relatively rare headache disorder associated only with airplane travel; in particular pain begins during taking off or landing or both [3].

The first adult case of AH was reported in 2004 [4]. Its prevalence is unknown and the underlying pathophysiology is uncertain, although sinonasal barotrauma has been proposed [46].

In 2013 Mainardi et al. [7] collected clinical data of 75 patients with symptoms suggestive of AH and proposed provisional diagnostic criteria.

There has been a steadily increase in the number of reported cases in the following years: up to now, 275 adult cases have been described in the literature [720] and, recently, two systematic reviews have been published [21, 22]. Most of the known cases of AH are young males. In all cases, symptoms are highly stereotyped. The pain is typically reported as severe and may be described as jabbing, stabbing, or pulsatile in quality. It is usually unilateral and localized to fronto-orbital and fronto-parietal regions. The headache is short-lived, lasts less than 30 min, and occurs exclusively in relation to airplane travel (most frequently during airplane descent). Accompanying symptoms are usually absent.

So far only 5 cases within the pediatric age group have been described [2325].

The aim of our study is to investigate the prevalence and characteristics of AH in a large group of children suffering from primary headaches, taking into account experts’ opinion about the pediatric secondary headache diagnostic criteria of ICHD-III beta [26].

Patients and methods

This study is a multicentric pediatric cohort study. Patients with symptoms suggestive of AH were recruited from 9 Italian Pediatric Headache Centres.

During the study period, all patients were solicited to take part in the study. Following an explanation about the study purposes, each patient was handed a structured questionnaire, aimed at obtaining all the relevant information that could clinically distinguish this peculiar disorder. The questionnaire met the ICHD-III criteria [27].

The inclusion criteria were:
  1. A.

    At least two episodes of headache fulfilling criterion C.

     
  2. B.

    The patient is travelling by aeroplane.

     
  3. C.

    Evidence of causation demonstrated by at least two of the following:

     
  4. 1.

    headache has developed during the aeroplane flight

     
  5. 2.
    either or both of the following:
    1. a)

      headache has worsened in temporal relation to ascent following take-off and/or descent prior to landing of the aeroplane.

       
    2. b)

      headache has spontaneously improved within 30 min after the ascent or descent of the aeroplane is completed.

       
     
  6. 3.
    headache is severe, with at least two of the following three characteristics:
    1. a)

      unilateral location.

       
    2. b)

      orbitofrontal location.

       
    3. c)

      jabbing or stabbing quality.

       
     
  7. D.

    Not better accounted for by another ICHD-3 diagnosis.

     
  8. E.

    Age ≤ 18 years.

     

The structured questionnaire was composed of 32 questions and included two sections: medical history and details of nature of AH.

A total number of 727 children participated in this survey. The questionnaire was completed by 637 subjects.

Most of the cases were females (364 females, 273 males). The mean age of patients was 11.3 years (range 3.1–18.0).

Results

Age at onset

Among 320 patients who flew during their lifetime, only 15 (4.5%) had AH. Most of the cases were females (12 females, 3 males). The mean age at recruitment was 12.4 years (range 8.2–16.0); the mean age at headache onset was 7.2 years (range 3.1–11.1).

History of coexistent primary headaches

A specific section of the questionnaire focused on the possible coexistence of a primary headache, according to the ICHD-III [27]. In the total study population (n = 637), the most commonly associated primary headaches were migraine (n = 456; 71.6%) and tension-type headache (n = 137; 21.5%). In 29 patients (4.5%) two different coexistent primary headaches could be diagnosed; no patient reported symptoms suggestive of cluster headache (Table 1).
Table 1

Classification of headaches in patients

Headache type

N

%

Migraine without aura

368

57.8

Episodic tension-type headache

82

12.9

Migraine with aura

74

11.6

Chronic tension-type headache

55

8.6

Migraine + tension-type headache

29

4.5

Other primary headaches

15

2.3

Chronic migraine

14

2.2

Total

637

100

The neurological examination was unremarkable. Basic biochemical and hematologic tests and brain magnetic resonance imaging revealed no abnormalities.

Twelve children (80%) with AH suffered also from migraine. Two patients (13.4%) with AH had also tension-type headache. One patient (6.7%) suffered from new daily persistent headache (Table 2).
Table 2

Concurrent primary headaches in AH patients

Headache type

N

%

Migraine with aura

7

46.7

Migraine without aura

5

33.3

Episodic tension-type headache

1

6.7

Chronic tension-type headache

1

6.7

New daily persistent headache

1

6.7

Total

15

100

Upper respiratory tract disorders

A personal history for allergy was reported by 3 patients (20%), and for sinus infection by 3 patients (20%). No patients had symptoms and/or signs related to inflammatory sinus disorders following an ENT specialist evaluation, performed immediately after the attack.

Clinical features of airplane headache

The clinical characteristics of AH were quite peculiar.

First episode

Seven children (46.7%) presented AH since the first flight experience.

Two patients (13.3%) flew 3–6 times per year, and seven patients (46.7%) flew less than one per year.

Consistency of attacks

In 7 children (46.7%) the same type of headache recurred consistently on separate flights; for those patients the pain started exclusively during landing in two, both during take-off and landing in three, during take-off in one and during cruising in one. The attacks occurred in more than 50% of flights only in one child (n = 1/15, 6.7%); for this patient the pain started only during take-off. The attacks occurred in less than 50% of flights in 3 patients (20%): exclusively during landing in two and also during cruising in one. In 4 cases (26.7%) the attacks were occasional and unpredictable. One patient reported the occasional occurrence of attacks during cruising only in the case of short-haul flights.

Timing

AH can occur at any time during the flight. More specifically, in three patients (20%) the attacks occurred exclusively during landing; in three patients (20%) AH started only during take-off. Five patient (33.5%) reported headache onset during cruising. In three patients (20%) AH started during both take-off and landing, and in one patient during cruising and landing (Table 3). No patients reported the possible difference in altitude between the arrival and departure airport as potential aggravating or trigger factors.
Table 3

Headache onset with respect to flight timing

 

Female n (%)

Male n (%)

Only during landing

3 (20)

0

Only during take-off

1 (6.7)

2 (13.3)

During cruising

4 (26.7)

1 (6.7)

During both landing and take-off

3 (20)

0

During both cruising and landing

1 (6.7)

0

Total

12 (80)

3 (20)

Duration

The duration was less than 30 min in all patients.

Intensity

The pain intensity was defined as severe by 10 (66.7%), moderate by 3 (20%), and mild by 2 (13.3%) patients.

Quality of pain

Quality of headache was most frequently defined as pulsating (8 cases, 53.6%). Other definitions were: pressing in 4 (26.7%), tightening in 3 (20%) patients.

Localization of headache

In the majority of patients (12/15, 80%) the pain was bilateral. In the remaining 3 cases (20%) headache was unilateral; in these cases, the pain constantly recurred on the same side throughout the different attacks in two cases, while in one case (6.7%) the pain occurred on the opposite side in subsequent flights. The pain was more frequently localized to the frontal region (9/15, 60%). In three subjects (20%) the pain spread to the whole head.

Emotional impact

Only three children (20%) were concerned with the fear of suffering from a further attack and therefore were negatively predisposed for future flights. Among these subjects, 2 (13.3%) continued to fly with anxiety and/or worry; one (6.7%) decided to fly only if strictly necessary.

Accompanying symptoms

These were reported by 11 patients (73.3%): tearing, photophobia, phonophobia. No conjunctival injection, nausea, vomiting were reported.

Self-administered manoeuvres

Two patients (13.3%) performed one spontaneous maneuver in order to decrease the intensity of the attacks and to obtain some relief. The self-administered maneuvers were: pressure on the pain site and bracelet. One patient reported a reduction of pain intensity.

Pharmacological treatment

Ten patients (66.7%) did not take any drugs. The remaining 5 patients (3/5 females) used the following medications: acetaminophen (15 mg/kg), ibuprofen (10 mg/kg) and ketoprofen (1.5 mg/kg) were taken within few minutes after the headache onset, with rapid relief (Table 4).
Table 4

Demographic characteristics and clinical reports of the AH patients

Subject no

Gender

Age (year)

Duration of AH (minutes)

Intensity of pain

Quality of pain

Localization of the headache

Pharmacological treatment

1

F

12.6

30

5

Pressing

Temporal, bilateral

No

2

F

9.7

30

2

Pulsating

Frontal, unilateral

No

3

M

10.5

20

8

Pulsating

Frontal, bilateral

No

4

F

12.8

30

4

Pressing

Frontal, bilateral

No

5

F

8.2

20

9

Pulsating

Frontal, bilateral

Yes, acetaminophen

6

M

11

30

1

Pulsating

Frontal, bilateral

Yes, acetaminophen

7

F

15.5

20

8

Pressing

Frontal, bilateral

No

8

F

11

15

8

Pressing

Diffuse, bilateral

No

9

F

16

25

6

Pulsating

Frontal, bilateral

No

10

F

14

25

8

Tightening

Temporal, bilateral

No

11

F

12

20

9

Pulsating

Diffuse, bilateral

Yes, ketoprofen

12

F

16

30

8

Pulsating

Frontal, bilateral

No

13

F

15

30

9

Pulsating

Frontal, bilateral

No

14

M

9

30

7

Tightening

Diffuse, unilateral

Yes, acetaminophen

15

F

12.5

30

8

Tightening

Occipital, unilateral

Yes, ibuprofen

Discussion

The present study was performed on a selected population affected by primary headaches referring to 9 Italian Pediatric Headache Centres and described in details the clinical features of 15 children suffering from brief headache during airplane travel. The clinical features of AH in our pediatric population were quite peculiar and differed from those described in adulthood [720].

Even though it is not possible to directly compare these data with those on AH adults recruited from the general population, it seems that AH features significantly differ between the adult and the child population in terms of several clinical features (intensity, distribution of pain, presence and type of accompanying symptoms, male to female ratio, etc). AH is strictly unilateral in the vast majority of adult cases, its phenotype resembles somehow cluster headache [7]. Moreover, only 20% of the pediatric patients presented a negative predisposition to future flights compared to 80% of the adult patients [7] and no one among the pediatric patients appeared to have restlessness or anxiety during the attack, maybe due to the less intensity of the pain. Children showed less frequently concern for subsequent airplane travel maybe for a reduced memory of the painful experience, for the lower intensity of pain and for a greater curiosity for future airplane travels. Moreover, differently from adults [7], no pediatric patients presented an easily recognizable postictal long-lasting mild headache phase after the AH acute attack.

All our patients suffered from at least one type of primary headache, as they were recruited in specialized pediatric Headache Centres. Only 20% of adults reported in the literature suffered from a concomitant primary headache [521]. Interestingly, we have found a relevant association between AH and migraine with aura. Baldacci et al. [10] reported a patient with AH also affected by migraine with aura: this primary headache is more rare compared to migraine without aura and episodic tension-type headache in the pediatric population. Therefore, the association between AH and migraine with aura does not seems to be incidental and deserves further epidemiological studies to better understand the etiopathogenetic mechanisms of this association.

In half of our AH cases, the first attack was concomitant with the first flight and in 46.7% of them occurred during each flight. In adult population the first AH during the first flight occured only in 14% of cases; that is a significant difference. It is likely that in the pediatric population, the headache attack during the flight warns the parents and therefore it is reported more frequently since the first attack.

The sex ratio was different for pediatric AH compared to adults [720] and was skewed toward females (80%) in our young patients. In adult population, the AH was unilateral and it was localized to the fronto-orbital area [720]. The quality of the headache was often defined as jabbing, stabbing and sharp [720]. Signs like tearing, conjunctival injection, nausea, vomiting, photophobia, phonophobia were observed rarely7–20, while in our study population some of them (tearing, photophobia, phonophobia) were reported by the majority (73.3%) of patients.

Even though the pain was intense in most cases, only one third used analgesics both in children (33.3%) and in adults (38%) [720, 2325].

Two patients performed one spontaneous maneuver to reduce the pain intensity and to obtain some relief, similar to the maneuvers carried out by patients with migraine, tension-type headache and cluster headache, as previously reported [25].

To the best of our knowledge, so far only 5 pediatric AH patients have been reported in the literature: in 2008 Mainardi et al. [23] described the first pediatric patient with AH; in 2010 Ipekdal et al. [24] described three pediatric AH cases aged between 12 and 14 years; the fifth case was reported in 2015 [25].

In the study of Ipekdal et al. [24], nasal mucosal inflammation, adenoidal and tonsillar hypertrophy and sinusitis were the pathophysiological mechanisms found to be responsible for AH. In all the 3 patients, AH has been solved by treating the underlying disease. In fact, they experienced other airplane travels and reported that they performed headache-free landings without any complication after the treatment.

In our study three children had a past history of sinus infections but none had any clinical evidence of an active sinus disorder during AH attacks.

Comparing the previously reported 5 cases with our series, we found that quality and intensity were similar, while site of pain was previously reported as unilateral [2325], differently from our cases. A recent research article confirmed that headache caused by airplane travel is not necessarily unilateral, the description of headache may be not specific and the past history of any type of headache should be considered [26].

Given the peculiar clinical features of AH in the pediatric age compared to the adult population, more attention is needed towards this form of secondary headache, for better recognition even without the concomitance of other primary headaches: therefore the next edition of the ICHD should mention this entity also for the pediatric age.

Conclusions

Our study shows that AH is not a rare disorder in children affected by primary headaches and highlights that features of AH in children are peculiar and differ from those described in adults.

The exact mechanism underlying AH remains unclear, but it has been suggested a multifactorial pathogenesis [28].

Further studies are needed in the general pediatric population to confirm the actual frequency of AH; in particular population-based studies might address the issue of analyzing AH incidence, considering a bigger sample not selected in specialized Headache Centres, with and without other concomitant headache condition, with a long-term follow-up evaluation.

Notes

Abbreviations

AH: 

Airplane headache

ENT: 

Ear, nose and throat

ICHD-III

International Classification of Headache disorders, 3rd edition

Declarations

Acknowledgements

The Authors wish to thank patients and their families for their kind cooperation.

Funding

The authors have no funding to report.

Availability of data and materials

The datasets used and/or analysed during the current study (not included in this published article) are available from the corresponding author on reasonable request.

Authors’ contributions

DDC: acquisition of data, analysis and interpretation of data, drafting of the manuscript. IT: design and implementation of the research, analysis of the results, drafting and revision of the manuscript. AMT, BB, MGL, LM, VR, MS, VS, AV, SZ: acquisition of clinical data, material support. SS, MG: study supervision and material support. AV, PAB: study concept and design, critical revision of the manuscript for important intellectual content. All authors read and approved the final manuscript.

Ethics approval and consent to participate

All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Consent for publication

For this type of retrospective study formal consent is not required.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors’ Affiliations

(1)
Juvenile Headache Centre, University of Padua, via Giustiniani 3, 35128 Padua, Italy
(2)
L’Aquila, Department of Pediatrics, San Salvatore Hospital, University of L’Aquila, L’Aquila, Italy
(3)
Department of Child and Adolescent Neuropsychiatry, University Hospital of Cagliari, Cagliari, Italy
(4)
Child Neuropsychiatry Unit, Department of Neuroscience and Sense Organs, University of “Aldo Moro” Bari, Bari, Italy
(5)
Child Neuropsychiatry Unit, Di Cristina Hospital, ARNAS civico, Palermo, Italy
(6)
Department of Child Neuropsychiatry, Università degli Studi di Bologna Scuola di Medicina e Chirurgia, Bologna, Italy
(7)
Neurologic and Psychiatric Sciences Department, Ist Neurological Clinic, Bari, Italy
(8)
Department of Child Neuropsychiatry, Università degli Studi di Palermo, Palermo, Italy
(9)
IRCCS “La Nostra Famiglia - E. Medea”, Pasian di Prato, Udine, Italy

References

  1. Strine TW, Okoro CA, McGuire LC et al (2006) The associations among childhood headaches, emotional and behavioral difficulties, and health care. Pediatrics 117:1728–1735View ArticleGoogle Scholar
  2. Brenner M, Oakley C, Lewis D (2008) The evaluation of children and adolescents with headache. Curr Pain Headache Rep 12:361–366View ArticleGoogle Scholar
  3. Titlić M, Demarin V (2008) Airplane headaches-two new cases and a review of the literature. Acta Med Croatica 62:229–231PubMedGoogle Scholar
  4. Atkinson V, Lee L (2004) An unusual case of airplane headache. Headache 44:438–439View ArticleGoogle Scholar
  5. Berilgen MS, Mungen B (2011) A new type of headache, headache associated with airplane travel: preliminary diagnostic criteria and possible mechanisms of aetiopathogenesis. Cephalalgia 31:1266–1273View ArticleGoogle Scholar
  6. Mainardi F, Maggioni F, Lisotto C et al (2013) Diagnosis and management of headache attributed to airplane travel. Curr Neurol Neurosci Rep 13:335View ArticleGoogle Scholar
  7. Mainardi F, Lisotto C, Maggioni F et al (2012) Headache attributed to airplane travel (‘airplane headache’): clinical profile based on a large case series. Cephalalgia 32:592–599View ArticleGoogle Scholar
  8. Berilgen MS, Mungen B (2006) Headache associated with airplane travel: report of six cases. Cephalalgia 26:707–711View ArticleGoogle Scholar
  9. Evans RW, Purdy RA, Goodman SH (2007) Airplane descent headaches. Headache 47:719–723View ArticleGoogle Scholar
  10. Mainardi F, Lisotto C, Maggioni F (2007) Headache attributed to airplane travel: three new cases with first report of female occurrence and classifying criteria. J Headache Pain 8(Suppl):12Google Scholar
  11. Mainardi F, Lisotto C, Palestini C et al (2007) Headache attributed to airplane travel (‘airplane headache’): first Italian case. J Headache Pain 8:196–199View ArticleGoogle Scholar
  12. Marchioretto F, Mainardi F, Zanchin G (2008) Airplane headache: a neurologist's personal experience. Cephalalgia 28:101PubMedGoogle Scholar
  13. Kim HJ, Cho YJ, Cho JY et al (2008) Severe jabbing headache associated with airplane travel. Can J Neurol Sci 35:267–268View ArticleGoogle Scholar
  14. Coutinho E, Pereira-Monteiro J (2008) ‘Bad trips’: airplane headache not just in airplanes? Cephalalgia 28:986–987View ArticleGoogle Scholar
  15. Baldacci F, Lucetti C, Cipriani G et al (2010) Airplane headache’ with aura. Cephalalgia 30:624–625View ArticleGoogle Scholar
  16. Kararizou E, Anagnostou E, Paraskevas GP et al (2011) Headache during airplane travel (“airplane headache”): first case in Greece. J Headache Pain 12:489–491View ArticleGoogle Scholar
  17. Cherian A, Mathew M, Iype T et al (2013) Headache associated with airplane travel: a rare entity. Neurol India 61:164–166View ArticleGoogle Scholar
  18. Bui SB, Petersen T, Poulsen JN et al (2016) Headaches attributed to airplane travel: a Danish survey. J Headache Pain 17:50View ArticleGoogle Scholar
  19. Mainardi F, Maggioni F, Lisotto C, Zanchin G (2015) Should aircrafts never land? Headache attributed to airplane travel: a new series of 140 patients. J Headache Pain 16(suppl1):166View ArticleGoogle Scholar
  20. Purdy RA (2012) Airplane headache-an entity whose time has come to fly? Cephalalgia 32:587–588View ArticleGoogle Scholar
  21. Bui SB, Gazerani P (2017) Headache attributed to airplane travel: diagnosis, pathophysiology and treatment – a systematic review. J Headache Pain 18:1–14View ArticleGoogle Scholar
  22. Nierenburg H, Jackfert K (2018) Headache attributed to airplane travel: a review of literature. Curr Pain Headache Rep 22:48View ArticleGoogle Scholar
  23. Mainardi F, Broekmann R, Lisotto C, Maggioni F, Mampreso E, Zanchin G (2008) “Airplane headache” may occur in paediatric age: description of the first case. J Headache Pain 9:42Google Scholar
  24. Ipekdal H, Karadas O, Erdem G (2010) Airplane headache in pediatric age group: report of three cases. J Headache Pain 11:533–534View ArticleGoogle Scholar
  25. Rogers K, Rafiq N, Prabhakar P et al (2015) Childhood headache attributed to airplane travel: a case report. J Child Neurol 30:764–766View ArticleGoogle Scholar
  26. Ozge A, Abu-Arafeh I, Gelfand AA et al (2017) Experts’ opinion about the pediatric secondary headache diagnostic criteria of ICHD-III beta. J Headache Pain 18:113View ArticleGoogle Scholar
  27. Headache Classification Committee of the International Headache Society (IHS) (2018) The international classification of headache disorders, 3rd edition. Cephalalgia 38(1):1–211View ArticleGoogle Scholar
  28. Bui SBD, Petersen T, Poulsen JN et al (2017) Simulated airplane headache: a proxy towards identification of underlying mechanisms. J Headache Pain 18:1–10View ArticleGoogle Scholar

Copyright

© The Author(s). 2018

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