Headaches and SCUBA Diving

[Red Sea Shadow]

Diving headaches have spoiled many dive trips. As there are different causes associated with headaches and diving, it can be as simple as your mask strap being overly tight or as complicated as a symptom of decompression sickness (DCS). Here are some common causes, preventions, and treatments for diving headaches.

Sinus headache
A sinus headache is caused by a sinus squeeze during ascents or descents. The symptoms are pain in the forehead, pain in the face, or pain in the cheekbone area. A diving headache caused by a sinus squeeze is due to the failure in equalizing pressure. Another cause is the inflammation of the sinuses or nasal cavity due to allergies or cold. Remedies include slowing your ascents and descents or using decongestants. However, it’s better not to dive if you are sick.

Tension headache
Symptoms of tension headache are pain in the head and pain in the back of the neck. Tension headaches are caused by muscle strain due to anxiety and muscular rigidity. Clenching your jaw during the dive can also cause tension headache. To prevent the development of muscle strain and consequently tension headache, you must learn to relax in the water. Eventually you will stop getting this type of headache if you dive within your abilities, gain experience, and become comfortable in the water.

Migraine headache
Symptoms of migraine headache include severe pain, visual changes, weakness or numbness of the arm, and nausea. Also post-dive vomiting is one of the migraine headache consequences, but if coupled with other symptoms could indicate a DCS hit. If the diver has a history of migraine headaches, there could be a direct correlation between diving and the onset of the cranial pressure.

Many of the medications used to treat migraines contain drugs which will increase the risk of nitrogen narcosis. Unless they are able to take measures for preventing migraine attacks, people with migraines should not dive. Anyone who suffers from migraine headaches and wishes to dive must consult a physician, preferably one with knowledge and experience in diving medicine.

Carbon dioxide toxicity headache
A dull pulsing head pain after diving is usually a symptom of this type of headache caused by carbon dioxide toxicity. This headache is caused by carbon dioxide build-up in the body. The increase in waste gas is usually due to hypoventilation (too little air intake). Hypoventilation usually happens when a diver doesn’t take large enough breaths from his/her tank or doesn’t breathe often. Simply put, not breathing enough to get rid of the carbon dioxide created in the body will eventually lead to this type of headache.

Carbon dioxide build-up is also caused by the usage of inefficient dive equipment, especially at depths below 30 meters (100 feet) where the gas density increases. This creates greater work of breathing, which leads to creating more carbon dioxide. Given that carbon dioxide is way more narcotic than nitrogen, sense dulling is a potential impact of excessive carbon dioxide build-up.

The best treatment here is to take slow, deep breaths to reduce the build-up. Also use high performance regulators with good flow characteristics. Carbon dioxide headaches don’t respond well to pain relievers.

DCS headache
Headaches can also be a sign of DCS. DCS is caused by the formation of bubbles as dissolved nitrogen comes out of the tissues on ascent. DCS can lead to permanent physical impairment or death. Seek immediate medical attention if a diver complains of headache and has other signs of DCS like joint pain, swelling, skin rash, itching, dizziness, nausea, vomiting, ringing in the ears, or extreme exhaustion. A SCUBA diver is at risk of DCS when he/she does not decompress after long or deep dives before surfacing, or when he/she ascends too quickly or makes a panic ascent.

A word about dehydration
Dehydration is one of the most common problems, yet goes unrecognized. One of the first symptoms of dehydration is headache accompanied by dizziness, ranging from mild to severe.

The body uses fluids to maintain temperature. When the fluids go out, the body will concentrate fluids internally and peripheral flow is cut down. This in turn reduces the ability of the body to off-gas as the capillary exchange at the extremities became less efficient due to decreased circulation, which in turn invalidates all the decompression models. You may believe that you are off-gassing normally, whereas in reality, you are not. Watching your computer or following the tables won’t help because the models are no longer valid. Also the blood flow to the brain is reduced due to dehydration, which results in reduced oxygen flow to the brain. Headache and dizziness occur accordingly.

It is advisable to drink at least two liters of water a day. When engaged in SCUBA diving, it should be increased to about four liters a day.

 

[DocVikingo]

Hi Red Sea Shadow,

Thanks, Assar.

I would add to this list: mask squeeze, excessive constriction around the neck by thermal protection such as drysuits and similar gear issues (e.g., pressure on the neck from the tank valve), certain dental issues, cold water around an inadequately insulated head, saltwater aspiration, drugs such as caffeine and a wide variety of others, and various and sundry neck issues including hyperextension and cervical spondylosis.

I'd also like to note that a number of the statements in your text are open to discussion, but I'll point out just one for the moment.

Many of the medications used to treat migraines contain drugs which will increase the risk of nitrogen narcosis.

While there is theoretical reason to believe that certain medications used to treat migraines (and in fact any of a vast number of drugs that have drowsiness/sedation/sleepiness as a possible side effect) may be additive with or potentiate nitrogen narcosis, to the best of my knowledge your assertion has not been scientifically demonstrated.

Regards,

DocVikingo

 

[TSandM]

Nice capsule summary of some causes.

I would disagree, however, with the blanket statement that people who have migraines must either prophylax for them or not dive. Many people have only occasional migraine headaches, and others have migraines which are not incapacitating. Migraine must be evaluated on a case-by-case basis.

It is also not true that the body regulates temperature with fluids, although the rest of that paragraph is correct.

CO2 headaches ARE common in people who are skip breathing, but are probably MOST common in people who are taking rapid, shallow breaths which are not efficiently ventilating the air spaces. This type of CO2 headache is common in new divers.

Doc Vikingo, don't forget the "isolator jammed into the back of my head for an hour" headache!

 

[DocVikingo]

Doc Vikingo, don't forget the "isolator jammed into the back of my head for an hour" headache!

I feel your pain, TSandM.

Regards,

Doc

 

[Bubbletrubble]

It is advisable to drink at least two liters of water a day. When engaged in SCUBA diving, it should be increased to about four liters a day.

Thanks for the diving headache summary.

I am aware of the notion that being dehydrated can contribute to DCS. Given some of the data out there, it would seem that being well hydrated could/should be one of a diver's priorities. We all know that tank air is typically dehumidified/dry air and that this can dry out the mucous membranes in airway passages.

What I'm a little unclear about is the arbitrary recommendation to increase one's water intake to 4 liters per day. Furthermore, the recommendation could be misleading in the sense that a casual reader might think that one's hydration status is determined solely by water ingestion and not by drinking other fluids. We know this is not at all the case.

Would it be better to recommend that divers drink slightly more than their normal intake of fluids and monitor their urine output for signs of adequate "dilution" (light/clear-colored urine)?

 

[lulubelle]

Thanks for this post, it was very useful to me.

I have post dive headaches which resolve fairly quickly most of the time. I am well hydrated and breath normally during my dive. So I'm not sure what their root cause is.

Sometimes that post dive headache turns into a migraine, but generally after the dives are done. I carry a triptan on the boat but have only taken it post diving.

I'll give all of these things consideration!

L

 

[Red Sea Shadow]

Thanks for your comments guys.

One more thing to add is if you suffer migraine with visual disturbance before the headache you might have a PFO.

 

[InTheDrink]

I get some pretty bad headaches after dives. I'm pretty sure its CO2 build up. Some observations:

I try not to skip breathe (occasionally when taking photos/videos).
The are much more likely to occur on dives where effort (e.g. against current) is required.
They are not entirely predictable
I suspect that long shallow stops reduces their impact
My experience is that they are less likely or pronounced when diving Nitrox
I make sure I am super hydrated
I am a smoker. I don't smoke anymore before dives in case they cause headaches.

I think headaches after dives are VERY common. Might even be worth kicking off a poll.

 

[JonKranhouse]

Slippery Slope?

Sorry for the length of this post, but headaches and DCS involves a big can of worms. Here goes...

A list of possible causes of headaches after diving is a good thing. But without strongly cautioning that delays in treating a DCS headache with oxygen creates a VERY slippery slope. We don't want to encourage divers to deny their own possible symptoms of DCS type-2. DAN used to publish in their annual accident reviews a series of charts that showed how long-term disability dramatically increased when O2 or HBOT was delayed by just a few hours.

Nobody wants to think they've gotten bent, and they don't want to interrupt a group vacation with their possible need of HBOT. But inappropriate dithering - "Is it a mask squeeze or could it be DCS" should not delay O2. Delays might greatly worsen an outcome and cause life-long problems that would otherwise be prevented.

I'm NOT advocating that every single instance of a headache after diving be treated as DCS. Of course if a dive was dramatically less than the limits of a conservative dive table, "dithering" is very appropriate to determine the root cause. I've had my own share of sinus squeezes after a lay-off. But pretending there are not huge financial considerations which influence what divers are taught is a disservice to all divers.

PADI's Encyclopedia of Recreational Diving and even material from DAN (a for-profit dive insurance company owned by a non-profit parent) avoids strongly worded language that used to be taught to all divers. From The New Science of Skin and Scuba Diving (page 67 of the 1970 edition):

"Because nerve tissue can't survive such insults for very long, treatment has to be prompt, and is automatically given on one of the longer treatment tables. These things, incidentally, can occur after perfectly ordinary dives with supposedly adequate decompression…

The possible variety of symptoms of decompression sickness is so great that almost any abnormality which shows up after a dive has to be considered a possible "bend" unless it is obviously caused by something else. The "obviously due to something else" idea can be misleading. For instance, a diver who develops a sore knee after a dive may know that he hit it on a rock during the dive - but such injuries may favor development of a bend in the affected location. The fact that a dive was within the "zero decompression" limits or that proper decompression was given doesn't mean very much, either.

Even an experienced diving medical officer may have a tough time deciding whether a certain symptom is due to decompression sickness or not. Frequently, a "test of pressure" has to be given; and, if this is inconclusive, the patient may have to be treated just to be safe. (Emphasis added)

Almost every bend, if untreated, will produce permanent injury of some degree. Whether this will be negligible or serious depends on the location and severity of the case. The disability may not show up at once either.

There are two commandments (emphasis from original) about decompression sickness: (1) remember that almost anything can happen; and (2) when in doubt, treat, and treat adequately."
​

Financial conflicts of interest are not new in medical research. Perhaps this journal article published in 2000, about headaches and DCS, illustrates such a conflict? The context is military aviation (hypobaric medicine vs. hyperbaric). If you're a military aviator and you've got a severe headache after an altitude exposure (i.e. a potential for DCS that is physiologically almost identical to ascending after diving) - you are classified as having DCS. Do not pass "Go." You're treated for DCS type-2. This paper considers if the insult (i.e. headache) should be reclassified, sometimes, as type-1 (joint pain) rather than always classifying the headache as type-2 (neurological). A type-2 DCS hit grounds flight crews for a longer time.

The authors, 5 US Air Force doctors + 1 non-military Dr., cite the financial benefit to military organizations if this new classification were adopted. They justify this reclassification with the notion that the "sutures" connecting the sections of our skulls be considered "joints" for purposes of DCS classification and evaluation.

​

These 6 doctors offer no medical studies of DCS and headaches to justify this change to long-standing policy; just a few anecdotes and historic data RE frequency of DCS headaches in aviation. But no before/after SPECT scan brain imaging is provided.

The doctors conclude:

(A) if a headache could be cited by a military doctor as emanating from a skull suture, then a type-1 hit (i.e. joint pain) would be concluded, thus requiring the crew member to return to flight status much more quickly vs. a DCS-type-2 hit (i.e. neurological), which grounds crews longer and a possibly obliges HBOT be given; and

(B) further study is required.​

But what's the potential harm to flight crews if these good doctors are wrong? The doctors ignored the rich body of international HBOT 1.5 ATA research, dating from the 1970's and today's best hope for helping vets suffering from Traumatic Brain Injuries (TBI) to maximize their recovery. HBOT 1.5 has had dramatic therapeutic impact for treating commercial divers with profound neurological deficits caused by repeated DCS insults. These commercial divers had "plateaued" with Navy table treatments, but gained back 20 IQ points via repeated HBOT 1.5 treatments. (Details go beyond the scope of this thread - suffice it to say there is great contention between certain UHMS / DAN "insiders" and key "outsider" HBOT MDs RE the use of HBOT to treat TBI and other neurological maladies - and how easily neurological functions can be harmed if DCS is not treated properly.)

Regardless of the validity of classifying cranial sutures as joints for DCS evaluation, military aviation protocol is clear: when someone experiences a severe headache after decompression, oxygen is given. Immediately. The paper cited begins with the anecdote that normobaric O2 quickly cleared a decompression headache almost immediately and no HBOT was required.

What's the take-away for recreational divers?
Should immediate normobaric O2 become a new standard for divers experiencing headaches after diving, and continue until DCS can be definitively excluded or the headache clears?

If you're at a remote location, what about in-water 100% O2 treatments with a FFM at 15 feet (1.5 PPO2 maximizes O2 to the brain). Higher PPO2 counter-intuitively causes lower brain O2 / blood glucose levels vs. 1.5 PPO2, per many international peer-reviewed studies.

The neurological spike of O2 and glucose at 1.5 PPO2 could explain Donald's "off-oxygen" phenomenon (i.e. an ox-tox hit when ascending, if bottom PPO2 was significantly higher -- back then ~2.0 PPO2 was allowed).

You'll find this interview with Capt. George Hart, MD, a past president of the UHMS before it moved to the Duke campus, VERY interesting. This is a MUST READ for medical professionals in diving. And anyone interested in HBOT. Or politics. As you read this interview, remember that Peter Bennett, the founder of DAN, became the executive director of the UHMS after his forced retirement from DAN.

Are you wondering why the use of HBOT to treat neurological maladies are almost never published in the UHMS' journal (the UHMS is based at Duke University)? Follow the money.

Paul Harch MD, an HBOT and diving medical specialist, is arguably the leading MD in the USA to push for HBOT 1.5 for some of the 320,000 veterans suffering from TBI. Harch's testimony to Congress in 2009 details how a panoply of antidepressant drugs - most with black-box warnings - are being prescribed to vets with TBI, despite lack of FDA approval for this "off-label" use. None of these drugs repair the underlying physiological damage - only HBOT potentiates the body's natural ability to heal itself.

How political could this be?
Based upon dramatic improvements by 100% of vets with TBI who have been treated with HBOT 1.5 in early trials, and testimony supporting further use of HBOT by two of the Joint Chiefs, two committees of the House of Representatives passed, unanimously, an amendment to the Department of Defense's 2010 funding (H.R. 3326 for $636 Billion). Most amendments offered up are killed - they never get out of committee. Few are passed unanimously. Fewer still are passed the same day they're offered up. Such was the promise of "Title-X" when it became the tenth and final amendment to HR 3326 -- the House's version -- on July 30, 2009:

Sec. 1001. Not later than 60 days after the date of the enactment of this Act, the Secretary of Defense shall submit to Congress a report on the use of hyperbaric oxygen therapy (in this section referred to as `HBOT') under the Secretary of Defense. Such report shall include the following:
(1) The number of members of the Armed Forces, veterans, and civilians being treated with HBOT.
(2) The types of conditions being treated with HBOT and the respective success rates for each condition.
(3) The current inventory of all hyperbaric chambers being used by the Secretary of Defense (including the locations, the purposes, and the rate of use of such chambers).
(4) Any plans for expanding the use of HBOT for treatment.​

--
The above House amendment was killed behind the closed doors of the Senate Appropriations committee on September 10, 2009. The amendment called for a REPORT. Just a report. A trivial expense. But then some more of the truth would be out.

Meanwhile, Japan, Russia, China and many countries in Europe are surpassing the USA in the broader use of HBOT.
http://www.rlk.biz/ScubaImages/China_HBOT_Meeting.jpg

Hiding the truth is not a Left vs. Right issue. It's Right vs. Wrong.

How can ScubaBoard members help end conflicts that impact the health and quality of care veterans receive? Start here to learn more...

 

[InTheDrink]

Thanks for your post JK and if your avatar is actually you, it must be said you're impossibly handsome

Your post goes way beyond comprehensive but it does lack one thing: a summary.

I know you have a section labelled "What's the take-away for recreational divers?" but it's not really a summary of your thoughts.

I, like many many divers I imagine, get headaches fairly frequently when diving. I am often on the edge of NDLs one side or another. I typically appropriate the headaches to either unintentional skip breathing or exertion. The headaches can be profound and I often take a few pills to ease the pain as well as re-hydrating like crazy. I currently do not, at all, view these headaches as any indication of any kind of DCS and have never had any other symptoms so I'm pretty sure it's not DCS even of the mildest kind.

So, in simple terms, what is your statement? Are you suggesting that headaches be considered as potential DCS indications? Unless I'm very wrong I would suspect if this were true and if people believed it that DAN membership costs would spike pretty quickly. Is there any evidence that normal headaches from diving without any other symptoms have any indication of DCS?

Thanks,
John