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"
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
"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" 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 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 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
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
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
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.
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
Post-Traumatic Headaches- Non-Penetrating Head Trauma
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 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.
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
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
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 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.
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.