Headache Medicine 2020, 11(4):81-84 ISSN 2178-7468, e-ISSN 2763-6178

ASAA

DOI: 10.48208/HeadacheMed.2020.24

Headache Medicine

Original

Ponytail headache (external-traction headache): prevalence,

characteristics and relationship with migraine

Larissa Paes Barreto Carolina Reis Daniella Araújo de Oliveira Marcelo Moraes Valença

Neurology and Neurosurgery Unit, Hospital das Clínicas, Federal University of Pernambuco, Recife, Pernambuco, Brazil

Abstract

Introduction

Despite its frequent occurrence, external-traction headache (previously named as “ponytail

headache”) is scarcely documented in the literature.

Objective

In the present study we set out to estimate the prevalence of ponytail headache and its relationship

with migraine.

Methods

One hundred and thirty women (27.7±11.1 years of age), 108 of them reported a previous history

of primary headache [81/130 (62.3%) migraine or probable migraine and 27/130 (20.8%)

non-migraine headache; 22/130 (16.9%) did not report any previous episode of headache],

were requested to wear a ponytail for 60 minutes, removing it only in case of pain. When pain

occurred, it was recorded for the latency between the placement of the ponytail and the onset of

the pain, its duration and characteristics. The women also lled out a questionnaire on previous

headache episodes.

Results

During the 60 minute-period, 52/130 (40%) women had ponytail headache elicited by the

experiment. There was a higher prevalence of ponytail headache in those who reported previ-

ous episodes of primary headache [48/108 (44.4%)], compared to those who did not [4/22

(18.2%)] (p=0.022). The migraineurs had more ponytail headache than non-migraneurs [39/81

(48.2%) versus 9/27 (33.3%), p=0.180] with a positive history of primary headache and they

also had more than those without [4/22 (18.2%)] (p=0.012). The group of women with migraine

also presented more ponytail-induced headache than non-migraineurs combined with the group

of individuals without a previous history of headache [13/49 (26.5%), OR 2.57, 95%CI 1.19-

5.55; p=0.015]. Migraine-like episodes were trigged in 3/52 (5.8%) by the experiment, all three

migraineurs. The latency time for the beginning of ponytail headache during the experiment was

21.5 ± 15.4 min and the duration was 76.0±159.3 min.

Conclusion

The prevalence of ponytail headache in our study was 40% and was statistically higher in

migraineurs.

Marcelo Moraes Valença

mmvalenca@yahoo.com.br

Edited by

Mario Fernando Prieto Peres

Keywords:

Ponytail

Headache

Migraine

External-traction headache

Woman

Pain

Received: September 20, 2020

Accepted: November 30, 2020

ASAA

Barreto LP, Reis C, Oliveira DA, Valença MM

Ponytail headache (external-traction headache): prevalence, characteristics and relationship with migraine

Introduction

espite of its frequent occurrence, the headache caused

by wearing a tight ponytail (ponytail headache, currently

named as external-traction headache)

is scarcely documented

in the medical literature.

In a cross-sectional study, Blau

observed a 53.8% prevalence of ponytail headache among

the 90 women interviewed.

The simple act of loosening the hair in order to relieve the

headache probably makes people think that it does not

merit any particular attention. Ponytails, however, are part

of the everyday lives of a large number of women, being in

some cases worn compulsorily as part of their professional

uniforms or optionally during athletic performance. In addition,

Headaches may be triggered by a ponytail without the

individual realizing that the ponytail may be the cause of

the headache. In very young girls a ponytail might trigger a

headache, and this is frequently overlooked by the parents.

For this reason, we believe that it may have a high negative

impact on the quality of life of some individuals. Based on

the theory that ponytail use may cause peripheral and central

sensitization in the nociceptive system of migraineurs, resulting

in a state of hyperexcitation of the pathways of pain control

systems

3-5

, we hypothesized that ponytail headache may be

more prevalent in migrainous women and may contribute to

the maintenance and exacerbation of this condition.

The objective of this study was to estimate the frequency of

ponytail headache in women to clinically characterize this

type of headache and to investigate its relationship with

migraine. To this end, we used an experimental model to

trigger the headache, requesting the subjects to wear a

ponytail continuously for 60 minutes.

Methods

A group of 130 women, between 15 and 60 years of age,

from the Metropolitan Region of Recife, were the subjects

of an experiment in which they had to wear a ponytail

continuously on the top of their head for 60 minutes. The

study was approved by the Ethics Committee of CCS/UFPE.

If they experienced any pain, they informed the researcher

immediately and the ponytail was removed, even before

the end of the 60-minute period. The researcher recorded

the time of latency between the ponytail placement and the

onset of the pain. Subsequently, the subject also informed the

researcher of the duration and characteristics of the

pain, when it was felt, its location (unilateral, bilateral or

diffused), quality (pulsating, stabbing, constrictive or continuous),

intensity (mild, moderate or severe) and whether it was

worsened by physical activities such as walking, domestic

tasks, climbing and going down

stairs, or whether it was accompanied by nausea and/or

vomiting, photophobia (whether light bothered more intensely

during the pain episode), and phonophobia (whether noise

bothered more intensely during the pain episode). All subjects

also informed the researcher regarding any previous history

of headache, in order to be classied as carriers of migraine

or non-migraine sufferers, based on the criteria established

by ICHD 3rd edition

The results were analyzed using the Graph Pad Prism

5.0 software. The data were presented as mean ±

standard deviation. The Kolmogorov-Smirnov test with

a 95% confidence interval was used for verifying the

type of distribution of the variables studied. The-Mann-

Whitney and Kruskal-Wallis tests were used for non-normal

distributions. The chi-square (c²) test was applied to

evaluate the categorical variables, according to the expected

frequencies. The level of signicance considered was p<0.05.

Results

Our sample was composed of 130 female volunteers,

between the ages of 15 to 60 years (27.7 ± 11.1). 108

of them reported a previous history of primary headache

according to the diagnostic criteria (ICHD 3rd edition)

suggested by the Headache International Society: 81/130

(62.3%) with episodes of headache attacks compatible with

migraine or probable migraine [10/81 (12.4%) with aura];

27/130 (20.1%) were classied as non-migraine sufferers, and

22/130 (16.9%) did not report any previous episode of headache.

During the 60 minute-period, 52/130 (40%) women had

ponytail headache elicited by the experiment. There was

a higher prevalence of ponytail headache in those who

reported previous episodes of primary headache [48/108

(44.4%)], compared to those who did not [4/22 (18.2%)]

(p=0.022, c²). The migraineurs had more ponytail headache

than non-migraneurs [39/81 (48.2%) versus 9/27 (33.3%)]

with a positive history of primary headache and they also

had more than those without [4/22 (18.2%); OR 2.57, 95%

CI 1.19-5.55; p=0.012 X

) (Figure 1). The group of women

with migraine also presented more ponytail-induced headache

than non-migraineurs combined with the group of individuals

without a previous history of headache [13/49 (26.5%),

p=0.015 X

Migraine-like episodes were trigged in 3/52 (5.8%) by the

experiment, all three migraineurs.

ASAA

Barreto LP, Reis C, Oliveira DA, Valença MM

Ponytail headache (external-traction headache): prevalence, characteristics and relationship with migraine

The age was statistically higher in the group which had

ponytail headache than in the group that did not present

headache during the experiment (31.4 ± 13.1 versus 25.2

± 8.9, respectively; p = 0.006, Mann-Whitney test). The

latency time for the beginning of ponytail headache during the

experiment ranged from 16 seconds to 58.7 min (21.5

± 15.4 min). The duration of the pain ranged from 15

seconds to 13 hours (76.0 ± 159.3 min). There were no

statistical signicant differences in the latency periods for the

beginning of ponytail headache among the three different

groups studied (21.2 ± 13.8 min in migraineurs; 21.7 ±

16.8 min non-migraineurs with a history of headache; 21.8

± 18.6 min with no previous history of headache; p = 0.980,

Kruskal-Wallis test).

There were likewise no statistical differences in the duration of

ponytail headache among the three different groups analyzed

(136.0 ± 229.0 min migraineurs; 34.0 ± 46.0 min non-

migraineurs with a history of headache; 18.4 ± 23.3 min with

no previous history of headache; p=0.316, Kruskal-Wallis test).

The characteristics of the headache are shown in Table 1. In

addition 16/52 (30.7%) with ponytail headache reported that

the pain was exacerbated by physical activities, 5/52 (9.6%)

that it was accompanied by photo- and phonophobia, and

11/52 (21.2%) that the episode was accompanied by nausea

and/or vomiting.

Ponytail Headache

M igrain e

N o n -M ig rain e

W ithout Headache

p =0.180

p =0.012

p =0.232

% of the individuals

Figure 1. Frequency of ponytail-induced headache.Individuals with

probable migraine were considered migraineurs. Chi-square test.

Discussion

The high prevalence of ponytail-induced headache in our

sample (40%), albeit lower than that reported by Blau

his study (53.8%), draws our attention to the importance of

considering this type of headache in the investigation of

headaches in women, especially among those who have to

wear a ponytail everyday as an integral part of their uniform.

In a prospective study with 82 policemen in Rio de Janeiro,

Krymchantowski and coworkers

analyzed the complaints of

headache clearly triggered by the wearing of a helmet. The

pain remitted in all the patients after the removal of the helmet.

As we know, a helmet is compulsorily worn as a part of the

uniform. Among patients with a previous history of migraine,

they found a prevalence of 30.5% of this type of headache

triggered by the continuous wearing of the helmet.

In our group, subjects with a previous history of migraine had

headache episodes that fullled the diagnostic criteria for

migraine attack elicited by the experiment, clearly indicating

that the wearing of ponytail type of accessories on the hair

may, in migraineurs, trigger migraine episodes. Thus, the

mechanical pulling of the hair leads to the onset of a

migraine-like attack. In migraine, the ability of external factors

to trigger headache attacks is well known.

8 -11

Furthermore,

surgeries were developed considering anatomical sites' ex-

istence as a possible anatomical triggering of headache

attacks.

12-15

Table 1. Characteristics of the headache attacks observed in the 52

volunteers who developed ponytail-induced headache during the 60

minute-period of the experiment

Migraine

(n=39)

Non-Migraine

(n=9)

Without Headache

(n=4)

Total (n=52)

Laterality

Unilateral 7 (17.9%) 3 (33.3%) 0 (0.0%) 10 (19.2%)

Bilateral 32 (82.1%) 6 (66.7%) 4 (100.0%) 24 (46.2%)

Quality

Pulsatile 12 (30.8%) 1 (11.1%) 1 (25.0%) 14 (26.9%)

Non pulsatile 27 (69.2%) 8 (88.9%) 3 (75.0%) 38 (73.1%)

Severity

Mild 22 (56.4%) 7 (77.8%) 4 (100.0%) 33 (63.5%)

Moderate 15 (38.5%) 1 (11.1%) 0 (0.0%) 16 (30.8%)

Severe 2 (5.1%) 1 (11.1%) 0 (0.0%) 3 (5.8%)

Worsens with

effort

16 (41.0%) 0 (0.0%) 0 (0.0%) 16 (30.8%)

Nauseas/

Vomiting

5 (12.8%) 0 (0.0%) 0 (0.0%) 5 (9.6%)

Photo- or

Phonophobia

9 (23.1%) 2 (22.2%) 0 (0.0%) 11 (21.2%)

Aura 2 (5.1%) 0 (0.0%) 0 (0.0%) 2 (3.9%)

The highest prevalence of ponytail headache may be

explained by the theory of peripheral and central sensitization

of the nociceptive system of migraineurs.

2,3

The ponytail may trigger migraine attacks in a similar way

observed with external compression headaches caused by

headwear that may induce long-term pressure on the

fore head or scalp. Thus, the clinician should advise the

migrainous patient to avoid wearing a tight ponytail, as well

ASAA

Barreto LP, Reis C, Oliveira DA, Valença MM

Ponytail headache (external-traction headache): prevalence, characteristics and relationship with migraine

as other pressuring devices (i.e. glasses, helmet, tight hats,

tiara, googles, etc.).

6,7,16

The systematic and continuous use of a ponytail may

have a high negative impact on a woman’s quality of life,

causing ponytail headache or acting as a trigger for

migraine like headache episodes that can be incapacitating.

The cessation of the use of a ponytail is the most effective

treatment in these cases.

Conclusion

The prevalence of ponytail-induced headache in our sample

was 40%, being more prevalent in migraineurs.

Conflicts of Interest: The authors declare no conicts of interest.

Author contributions statement

MMV designed this study, wrote, interpreted the data, and revised

this manuscript; DAO interpreted the data and revised this

manuscript; LPB and CR carried out the experiment with the

volunteers and revised this manuscript.

Larissa Paes Barreto

https://orcid.org/0000-0001-9805-4813

Carolina Reis

https://orcid.org/0000-0001-9863-4586

Daniella Araújo de Oliveira

https://orcid.org/0000-0002-6013-978X

Marcelo Moraes Valença

https://orcid.org/0000-0003-0678-3782

References

1. Valenca MM, de Oliveira DA. The Frequent Unusual

Headache Syndromes: A Proposed Classication Based on

Lifetime Prevalence. Headache 2016;56:141-152

2. Blau JN. Ponytail headache: a pure extracranial headache.

Headache 2004;44:411-413

3. Dodick D, Silberstein S. Central sensitization theory of migraine:

clinical implications. Headache 2006;46 Suppl 4:S182-191

4. Bendtsen L. Central and peripheral sensitization in tension-type

headache. Curr Pain Headache Rep 2003;7:460-465.

5. Burstein R. Deconstructing migraine headache into peripheral

and central sensitization. Pain 2001;89:107-110

6. Headache Classification Committee of the International

Headache Society (IHS) The International Classification of

Headache Disorders, 3rd edition. Cephalalgia 2018;38:1-211

7. Krymchantowski A, Barbosa JS, Cvaigman M, et al. Helmet-

related, external compression headache among police ofcers

in Rio de Janeiro. MedGenMed 2004;6:45

8. Holsteen KK, Hittle M, Barad M, et al. Development and Internal

Validation of a Multivariable Prediction Model for Individual

Episodic Migraine Attacks Based on Daily Trigger Exposures.

Headache 2020;60:2364-2379

9. Onderwater GLJ, van Oosterhout WPJ, Schoonman GG, et al.

Alcoholic beverages as trigger factor and the effect on alcohol

consumption behavior in patients with migraine. Eur J Neurol

2019;26:588-595

10. Tai MS, Yap JF, Goh CB. Dietary trigger factors of migraine and

tension-type headache in a South East Asian country. J Pain Res

2018;11:1255-1261

11. Silva-Neto RP, Peres MF, Valenca MM. Odorant substances

that trigger headaches in migraine patients. Cephalalgia

2014;34:14-21

12. Raposio E, Bertozzi N. Trigger Site Inactivation for the Surgical

Therapy of Occipital Migraine and Tension-type Headache:

Our Experience and Review of the Literature. Plast Reconstr Surg

Glob Open 2019;7:e2507

13. Vincent A, van Hoogstraten WS, Maassen Van Den Brink

A, et al. Extracranial Trigger Site Surgery for Migraine: A

Systematic Review With Meta-Analysis on Elimination of Headache

Symptoms. Front Neurol 2019;10:89

14. Seyed Forootan NS, Lee M, Guyuron B. Migraine headache

trigger site prevalence analysis of 2590 sites in 1010 patients.

J Plast Reconstr Aesthet Surg 2017;70:152-158

15. de Ru J. More comments on migraine trigger site decompression

surgery: focus on frontal headache. Headache 2015;55:702-

706

16. Rahmani Z, Kochanek A, Astrup JJ, et al. Helmet-induced

headache among Danish military personnel. Scand J Public

Health 2017;45:818-823