Not Tonight, Dear, I’ve Got a Headache!

1999, September/October Adirondac Adirondoc

By default, I seem to be the guy who winds up carrying the first aid kit on wilderness treks. Busman’s holiday, I guess.

Nothing very serious ever seems to necessitate breaking into the kit. By far the most predictable requests start in the late evening, especially on the second or third day of any trip. Invariably, one or more individuals in the group has a splitting headache and wants some immediate relief. On occasion, the headache develops within a few minutes of retiring for the night. At one point, I wondered if just being with me for a few days was enough to give people a headache. Although that well may be, I have heard from enough others to learn that this is a fairly common complaint.

Why would what should be a relaxing time in a stress-free environment give rise to a complaint we seem to associate with “tension”? There are actually a couple of simple explanations for this unpleasant phenomenon. Both are well known in the medical literature, and are amenable to very simple prevention. Strangely, they do not seem to have made it into standard wilderness first aid texts or backpacking handbooks.

First, let’s be clear about what these headaches are not. Although Mt. Marcy’s 5,344 feet may seem like a lot on a hot summer’s day, it is certainly not enough to cause acute altitude sickness (high altitude cerebral edema). Obviously, a severe headache in a trekker visiting Nepal would be an ominous development that would require serious evaluation. There may be dangers in the Adirondacks, but altitude is not among them.

The first factor that commonly contributes to “backpacker headaches” is dehydration. We are not talking here about the kind of profound dehydration that puts someone into shock. Rather, the problem is simply getting a bit behind on fluid replacement, maybe to the tune of two or three liters. Such dehydration is a well-known cause of headache. In fact, dehydration is one of the prime contributors to the headache of the common hangover. It is not unusual for a hiker, whose daily losses of water may be three or four times normal, to be a bit dehydrated by the second or third day of a trek.

Articles in backpacking magazines and books make a big deal about recommending specific volumes of water to consume. Such recommendations are bogus. There is no way in which meaningful “one-size-fits-all” advice can account for variations in body size and composition, activity level, or ambient temperature and humidity. The best advice is to look at what is coming out! Individuals who are well hydrated produce large volumes of dilute (i.e. clear) urine. Infrequent, small volume voiding of very concentrated urine is an indication that one’s hydration status is marginal. If this is accompanied by headache, the treatment is fluid. fluid, and more fluid.

The second cause of hikers’ headaches is subtler. but very real. About seven years ago, a group of investigators in Baltimore showed that caffeine withdrawal was commonly accompanied by severe headache. Campers who are used to drinking several cups of coffee daily and do not have it or another source of caffeine on their trip are liable to develop severe, seemingly unexplained headache within a day or two. With continued absence of caffeine. this problem disappears in a few more days.

Keep in mind that many carbonated beverages contain large amounts of caffeine. I have seen teenagers who never drink coffee but who consume several cans of cola daily develop severe caffeine withdrawal headaches. The best way to prevent such headaches is either to be sure that you are well stocked with Java in your pack. or undergo a week of gradual withdrawal from coffee-or cola-before your trek.

Both of these types of headaches are more easily prevented than treated. Pushing fluid or ingesting caffeine after a headache is established, unfortunately, does not lead to prompt relief. This may require one of the over-the-counter pain relievers. My colleagues who specialize in headaches (Yes, there are actually doctors who specialize in headaches!) are nearly uniform in recommending nonsteroidal anti-inflammatory agents (NSAIDS) such as MotrinTM. AdvilTM or OrudisTM as the most effective preparations.

One final word of warning. Most headaches are benign. On rare occasion, however, headache is the symptom of a major disturbance. A headache that is described as an individual’s ‘worst ever” or is accompanied by high fever, vomiting, alteration in consciousness. weakness or difficulty speaking is worrisome and constitutes indication for immediate evacuation from the backcountry.

~Thomas R. Welch. M.D.

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Topics: General First Aid