Headaches

[junior]

My friend Jeff and I went diving in the Keys two weeks ago. We had a great
time, except on day two during the ascent, Jeff got a real bad headache.
He's 20, weighs about 135 to 140, and about 5'8" tall. The first day
(around noon or 1 PM) we did two dives to about 25 feet each. Jeff and I
were both fine from those dives on the first day. The second day (around 9
AM or so) we did another dive to about 45' and when Jeff surfaced (we didn't
decompress at 15') his head began to hurt. While on the boat after we got
to our second dive site, he vomited. After getting back in the water to
rinse off 30 minutes top side, he said he felt better and wanted to dive
again. We went down to about 20 or 25 feet for about 30 minutes then went
back to the boat. When Jeff was surfacing again, he felt another vomiting
episode around 10 feet and surfaced right out of the water. About an hour
later back on shore he was fine. It wasn't sea sickness, the water was
smooth. Can you tell us what's happening and provide some advice for him to
prevent this from happening? He want's to dive, but this is putting a
damper on things as far as the fun goes.

Thanks in advance for your help,
Gene

 

[BillP]

Hi Gene:

Sorry to hear about your friend's trouble. Unfortunately it's usually impossible to tell exactly what caused a particular problem for any individual diver from a question on a scuba message board. There just isn't enough information available. But it is possible to discuss potential causes of headaches while diving, so I'll give it a shot.

One of the major concerns with headaches and nausea on or after ascent is the possibility of a decompression illness, i.e. decompression sickness (DCS, "the bends") or arterial gas embolism (AGE). The dive profiles that you describe don't sound particulary worrisome, but it would have been a good idea to do a safety stop on the third dive, and the rapid ascent that you describe on the fourth dive is concerning. Careful adherence to good diving practices will reduce the risk of a decompression illness.

Barotrauma is a common cause of headaches on ascent. A reverse sinus or ear squeeze is one cause. If the sinuses or ears clear on descent, but not ascent, expanding air will be trapped and cause pressure. This pressure can cause pain. If the reverse squeeze is in one ear it can cause a problem called "alternobaric vertigo" where the unequal ear pressure causes dizziness which can in turn cause vomiting. Diving in cold water can also cause sinus pain with an "ice cream headache", but if you were in the Florida Keys, I doubt that it was that cold. If the diver fails to equalize his mask, a mask squeeze can cause a headache. To avoid barotrauma, practice proper equalization techniques, avoid diving with a cold or congestion, and consider judicious use of decongestants to help clearing.

Carbon dioxide retention is a common cause of headaches while diving. If a diver reduces his breathing rate or breathes shallowly while diving his lungs won't exhaust as much CO2. The buildup of CO2 can cause a headache. Other causes of CO2 retention include heavy exertion (increased CO2 production), poorly functioning regulators (increased work-of-breathing), and deeper diving (denser air). Changes in CO2 and oxygen levels can trigger migraine headaches in some people. To avoid CO2 retention pay attention to your breathing pattern, avoid "skip breathing", don't hold your breath tooooo much to get that perfect photo, and buy a good quality regulator with a low work-of-breathing score and keep it tuned.

Carbon MONoxide poisoning is also a potential problem for divers, and can cause a headache and vomiting. Possible sources for carbon monoxide exposure include exhaust fumes from the car or boat, heating sources like space heaters if you're camping or improperly vented room heating, or even carbon monoxide contamination of the breathing mix.

Positional problems can also cause a headache. An ill fitting hood, a tight mask, or straining the neck to look forward while swimming horizontally can also cause a headache. Plain old anxiety can cause headaches, getting salt water up your nose bothers some people, partying too much the night before can sneak up on you the next day. I've probably just scratched the surface for possible causes for a headache and vomiting with diving. Hopefully someone else will chime in with their thoughts.

HTH,

Bill

[Edited by BillP on 10-14-2000 at 09:25 AM]

 

[junior]

Thanks Bill!

I spoke with a dive instructor that I work with (Scott) and my local diving instructor about his problem and Scott told me that Nitrox gas would eliminate his headaches. My local instructor, Dave, disagreed. Both said people have claimed that nitrox will make you feel less tired after diving (which is something I need, I usually nap almost every time after I dive). But Dave said that nitrox wouldn't help the headaches.

I'm trying to persuade Jeff into diving again so he can try breathing better. I used the entire tank of air on my dives, but Jeff usually had 1000 psi at the end of the hour. It could very well be that he's not breathing correctly, but then again, I don't know. The boat captain said that smaller framed people usually don't use as much air as larger framed people do. Jeff is 5'8" and 135 to 140, whereas I'm 6'1" and 225.

What are your thoughts about using Nitrox to dilute the CO2 gas buildup?

 

[BillP]

Hi Gene:

Well, you, Scott, and Dave all have good points, depending on what Jeff's problem was. If a diver develops a headache and nausea due to decompression sickness, diving nitrox "conservatively" (well away from the NDL's eg to "air" limits) might reduce the diver's risk of DCS and prevent the headache. But if the headache is caused by a sinus squeeze, improper mask clearing, neck strain, anxiety, CO2 retention, or any of the other potential causes I mentioned, then nitrox won't likely help. And if Jeff developed a decompression illness with the profiles that you two were diving, I doubt that it was the breathing mix that was the problem.

Your body creates CO2 as part of its metabolism. The higher your metabolism (say from vigorous activity) the more CO2 your body produces. Your body eliminates CO2 through the lungs. How much CO2 you eliminate through the lungs is much more dependent on how much breathing gas you physically move in and out of your lungs than it is dependent on what's actually in the breathing gas. The less you move gas in and out of your lungs, the less CO2 you excrete. There is only a tiny amount of CO2 in air (about 0.1% max) so you don't have to worry much about absorbing signifcant amounts from the breathing mix (unless there's something wrong with your gear, and you're rebreathing your exhaled air). Breathing nitrox would not help you eliminate CO2 significantly faster (like it helps with nitrogen). In fact the reverse can be true. Most people are driven to breathe by the build up of CO2 in their body. The more CO2 you have in your system, the faster and deeper you'll breathe. There are some individuals however who have lost this CO2 drive for respiration and are only stimulated to breathe when their oxygen level drops. If such a person (and they're very rare in diving) were to breathe nitrox, the oxygen in their system would be increased, their drive to breathe would be suppressed, they would retain more CO2, and their headache would worsen when they dived nitrox. Nitox won't "dilute the CO2 gas buildup". I think that Dave's probably closer to being right on this one.

Jeff might be using less air than you because he is smaller, because he is more comfortable in the water, because he isn't exerting himself as much, or any number of reasons. But if he's using less air because he's not breathing properly, nitrox is unlikely to help- only improving his breathing pattern will relieve the headaches. He could be developing a headache for any number of reasons other than CO2 retention however. I would be looking to figure out the cause of the headache before deciding on which solution for the problem to try.

HTH,

Bill

 

[junior]

Bill,

Thanks again. This has been very helpful. I'll pass the info along to him and hope he doesn't get sick on the next trip. The whole thing with nox was kind of a last resort idea. What you've said makes more sense.

 

[BillP]

Hi Gene:

You're still a long way from "last resorts". You've just started your analysis of the problem and haven't tried any solutions yet. If Jeff is interested in continuing to dive, there are still lots of possibilities. Was this his first time to go diving? If he's been diving before and never got the headache before he may never get one again. If this was his first dive trip, his problem still might have been something unique to that day and isn't necessarily doomed to recur.

What about a decompression illness? Think about your dive profiles on the trip. Did you push the no decompression limits on the third and fourth dives? Could you have done a safety stop? Was your ascent too fast? You can do everything right and still develop a decompression illness, but you might be able to alter you dive practices and reduce the risk.

What about barotrauma? Does Jeff have allergies that could be controlled? Did he recently have a cold? Did he have congestion on the days he dived? Did he try a decongestant? Did he equalize gently and frequently before and during descent? Did he remember to equalize his mask? There are plenty of options here.

What about CO2 retention? Is Jeff neutrally buoyant at depth so he doesn't have to hold his breath in or out to compensate for improper buoyancy control? Does he hold his breath to take pictures or "skip breathe" (pause too long between breaths to conserve air) reducing his air exchange? Does he have a poorly functioning regulator with too high a work of breathing score? Was he overweighted and diving with a jacket BC full of air or have an ill-fitting wetsuit that restricted his breathing? Was he uncomfortable or struggling at depth?

Could he have had carbon monoxide poisoning? Did he load his gear in the car with the hatch open and the engine running? (Just recently happened to a friend of mine.) Did he stand on the boat where he was exposed to exhaust fumes? Did just the stink of diesel fumes bother him and cause the problem? Did anyone else with a tank fill from the same place and time have a similar problem? Was the air in his tank tested for CO after the dives?

What about other causes? Was he positively buoyant during his dives causing him to swim head-down putting strain on his neck? Was his wetsuit or hood too tight making him uncomfortable? Did he party the night before? Did he simply have an illness unrelated to the diving? Was he nervous, anxious, struggling with his gear on the boat, etc.? Does he suffer from migraines? A headache and vomiting with diving can indicate a major problem or it might be no big deal. It's impossible to come up with a specific diagnosis or recommendations for any individual on a message board, but there are lots of possibilities for you and Jeff to look into. Dive instructors can be a great resource. Have Jeff go into his dive shop on a slow day and visit with his instructor for some leads and suggestions. He should also consider talking to DAN and even getting a referral to a physician familiar with dive medicine in his area for an evaluation. Contact information for DAN can be found at:

http://www.diversalertnetwork.org/contact/

If Jeff wants to continue diving, there are still lots of possibilities.

HTH,

Bill

 

[Iguana Don]

Junior,

My wife, she's an RN, told me that about 80-90% of all headaches are caused by dehydration. Don't forget to drink plenty of fluids before & after diving.

 

[junior]

Hey Bill,

Jeff has been diving before. He did a dive in West Palm Beach, FL, down to 75' and developed a headache on ascent then. He told me that was a CO2 headache and the dive boat captain put him on straight O2 for 20 minutes which seemed to fix the problem. He couldn't dive again that day. He has been diving before and the problem occured before. He and I read over the postings here and talked about the problems/solutions. I think we narrowed it down. He coughed up blood from his sinuses when we came back up from the 3rd dive. His mom, also and RN, suggested that a reverse squeeze was the problem. After he and I talked about that possibility, he told me his mask was too tight (something I didn't know before hand) during the whole trip. We are going to try diving again in Crystal River toward the middle of November when the manitees come back from sea (and before it gets too cold to skin it down here, water off the east coast is down to 68 degrees already and we both hate wearing suits).

I think it came down to a poorly fitted mask (too tight around his head). But also contributing it the cause was the fact that we didn't do a safety stop and we could have. This is something we are planning on for our next dive trip. I'm off to advanced open water class in two weeks, so that will help hone up my skills a bit better and hopefully we will both remember to talk about a safety stop before we dive.

Don's wife's suggestion of dehydration is a valid concern, too. I filled up on two 1 liters of water and Jeff had 4 OJ's (which I though tasted horrible) and one coffee from the motel that morning.

-Gene

 

[junior]

Originally posted by junior
My friend Jeff and I went diving in the Keys two weeks ago. We had a great
time, except on day two during the ascent, Jeff got a real bad headache.
He's 20, weighs about 135 to 140, and about 5'8" tall. The first day
(around noon or 1 PM) we did two dives to about 25 feet each. Jeff and I
were both fine from those dives on the first day. The second day (around 9
AM or so) we did another dive to about 45' and when Jeff surfaced (we didn't
decompress at 15') his head began to hurt. While on the boat after we got
to our second dive site, he vomited. After getting back in the water to
rinse off 30 minutes top side, he said he felt better and wanted to dive
again. We went down to about 20 or 25 feet for about 30 minutes then went
back to the boat. When Jeff was surfacing again, he felt another vomiting
episode around 10 feet and surfaced right out of the water. About an hour
later back on shore he was fine. It wasn't sea sickness, the water was
smooth. Can you tell us what's happening and provide some advice for him to
prevent this from happening? He want's to dive, but this is putting a
damper on things as far as the fun goes.

Thanks in advance for your help,
Gene

BillP,

Jeff and I are planning a dive again in Crystal River, FL, in about three or four weeks. He's planning to get a better fitting mask before we go this time. Besides that, and hydrating before the dive, I've heard that a decongestant such as Suedophed or some other type of OTC sinus aid contributes to equalizing during the decents. I did try this before, but I didn't notice any difference when I've dove w/o using Suedophed. Does using a sinus drug provide assistance with equalizing?

 

[BillP]

Hi Gene:

I'm glad to hear that Jeff is hanging in there. Decongestants can help with equalizing while diving if the problem with clearing is due to congestion. Whenever you take any drug, even (especially?) over-the-counter (OTC) drugs, you should make yourself aware of what is in it, what it's supposed to do for you, and what it can do to you. You should pick the least amount of drug(s) that will be effective without undue side effects. I'm a fan of single-ingredient OTC meds rather than "cure-all" combo's. Why take a combination of drugs that will treat your congestion, cough, itchy eyes, headache, fever, allergies, halitosis, and dandruff if your only problem is congestion?

If you have congestion before a dive, the easiest and safest solution is don't dive. But that isn't much fun. Next is to look for the source of the congestion. Try to treat the cause rather than the symptom. Do you have a allergies? A cold? A sinus infection? Just plain 'ole anatomy trouble with problems clearing? If allergies, starting an effective allergy treatment program is a good idea. Prevent the congestion before it starts. A cold? Some people swear by vitamin C, chicken soup, or zinc lozenges to shorten the course of the cold, but avoidance of cold germs by frequent hand washing and keeping your fingers away from your nose and eyes is the only thing that's really effective IMHO. If the cold symptoms are bad enough, just don't dive. If you can improve the symptoms enough with medication, well... use your judgment. Sinus infection? Best not to dive with an active infection. Get adequate treatment first. Anatomy trouble? Sometimes surgery will help if the problem is bad enough, but other times just a little decongestant will help.

There are lots of decongestants sold OTC. The simplest is saline nasal spray. It physically washes out the mucus to unclog sinus openings and has very few (if any) side effects. There are also many nasal sprays which shrink swelling, but many don't last long enough to get you through a morning's diving and even the long-lasting 12 hour sprays lose effectiveness over a few days. There's also a significant rebound effect when you stop taking them (your mucous membranes really swell) and you can become "addicted" to them if used long-term.

Pseudoephedrine (e.g. Sudafed and many others) is probably the decongestant most commonly used by divers. Remember that you want the least medicine(s) that works with the fewest side effects. There are no fewer than fifteen different formulations of Sudafed. Some have ingredients you don't want or need. Some may last too long, others not long enough. Plain "Sudafed Nasal Decongestant" (the little red round ones) contain 30mg of pseudoephedrine and can be taken every 4-6 hours with a max of 4 pills in a day. If you take them for several days, sometimes it seems like they're really only effective for about 3 hours. Say that you take the pill an hour before your dive to be sure it's working on your first dive, your first dive lasts 45 minutes, you have an hour surface interval, and the drug wears off half way through your second dive. You descended just fine when the medicine was still working, but now you're congested and have a reverse squeeze on ascent because your ears and sinuses can't equalize. Bad news. If you must take a decongestant, pick one that is long enough acting that it will start working before you dive and last through your diving day without wearing off.

"Comtrex Maximum Strength Multi-Symptom Cold & Cough Relief" has pseudephedrine 30mg like Sudafed, but it also contains phenylpropanolamine (PPA- the decongestant that's been in the news lately because the FDA wants to ban it), acetaminophen (which you might not need- it's Tylenol), chlorpheniramine maleate (an antihistamine that might be sedating and drying), and dextomethorphan (a cough medicine that can be sedating). Why take medicines you don't need that might have side effects that you don't want?

Pseudoephedrine can have side effects too. It can cause nervousness, dizziness, and sleeplessness. It should not be taken if you have heart disease, high blood pressure, thyroid disease, diabetes, glaucoma, or an enlarged prostate unless OK'ed by a physician. Do not take it with antidepressants in the monoamine oxidase inhibitor family. And don't take it if you don't need it. There is some concern that pseudoephedrine might increase the risk of oxygen toxicity on deep or nitrox dives.

As I mentioned before, always look for the cause of a problem and then come up with the safest effective solution with the least side effects. Good luck on your dives!

HTH,

Bill

As always, the above information is provided for discussion purposes only and is not meant as specific medical advice for any individual. Always consult with your own physician and DAN about any medical concerns before diving.

[Edited by BillP on 10-23-2000 at 06:48 AM]