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Outdoor First Aid

Headaches on the Trail? Here’s How to Deal

A pounding skull can ruin a hike, unless treated properly.

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On a trek through Nepal a few years ago, I woke to find our guide squeezing a friend’s head with both hands, like he was trying to crush a melon. My friend had woken with a severe headache, maybe because of altitude, or else from a long sunny day in the mountains. The squeezing helped a little—possibly a just distraction from the pounding. 

Far from home, a gnawing headache can provoke anxiety, frustration, or even misery and desperation. As a caregiver, headaches frustrate me, too.  They can mean anything from a minor inconvenience to life-threatening bleeding or brain swelling. The first step to treating headaches must be ruling out the dangerous stuff, and then offering whatever potentially helpful treatment may be at hand (although I’m not sure I can vouch for head squeezing). 

When should you worry? A “thunderclap” headache that reaches its maximum intensity minutes or even seconds after starting can be a sign of a true emergency and warrants prompt attention. Severe, “worst-ever” headaches warrant evacuation to front-country care. A headache associated with fever or neck stiffness, difficulty speaking, or weakness on one side of the body can also mean trouble. I wouldn’t mess with any of these in the backcountry—if you encounter any of these on the trail, evacuate as soon as possible.

Luckily, less ominous causes like tension headaches and migraines comprise the great majority of headaches. Both are uncomfortable, and sometimes unbearable. Many people with migraines have experienced similar symptoms in the past and can tell you whether they’re feeling a “typical” headache. Luckily, neither tension headaches or migraines are generally life-threatening, and can be safely treated in the wilderness (see below).

Changes in routine may predispose some hikers to headaches: Travel, lack of sleep, dehydration, and increased stress can be triggers. Caffeine withdrawal can do it too—so if you’re used to a bunch of double espressos every morning, plan for adequate caffeine intake on the trail, or else prepare for a withdrawal headache one to two days after cutting back (luckily, there’s a simple solution here). 

Hiking at elevation carries its own risks. A high-altitude headache often heralds the arrival of other mountain sickness symptoms, like poor sleep, dizziness, or nausea. Acclimatization time and anti-inflammatories like ibuprofen can help at altitude, and as always, descent is the best treatment for any type of altitude illness. Remember the warning signs: an abnormal neurologic exam, like impaired coordination (can’t walk, trouble with balance) may be a sign of life-threatening brain swelling, and that means it’s time to get help. And keep in mind that headache is an early symptom of carbon monoxide poisoning, so a headache while cooking in tents, huts, or other close quarters should raise alarm, especially if several people develop symptoms. 

Treatment requires some personalization. For some, ibuprofen, acetaminophen, or a strong cup of coffee does the trick. Otherwise, rest, hydration, or avoiding bright lights and loud sounds may be the key. Non-pharmaceutical treatments like relaxation techniques, biofeedback, and meditation can be great strategies for self-rescue. And familiarity with techniques like acupressure can be a welcome addition to your backcountry medical kit.

On a recent backpacking trip, one of my buddies woke at around midnight with a miserable headache. He looked awful: clammy, sweaty, nauseated. Luckily we quickly ruled out some of the red-flag headache causes: he wasn’t confused or weak, the headache came on gradually, and he had experienced similar migraine-type symptoms in the past. He stuck it out, and with some medication, rehydration, and finally some good sleep, we were back on the trail by morning.