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minutes, then rapidly subsiding. Associated clinical features may include unilateral nasal stuffiness,
rhinorrhea, eye redness, lacrimation and, at times, Horner’s syndrome2. A period with one or more
headaches per day, sometimes occurring with clocklike precision, lasting several weeks might typify a
“cluster”. These headaches are severe and incapacitating, requiring intensive treatment during the
episode. Intervals between clusters may be measured in years, during which medical certification
warrants consideration.
Operational implications:
Cluster headache is disqualifying for all classes of medical certification, since the headaches are
incapacitating and medical treatment commonly precludes safety-sensitive duties.
Aeromedical considerations:
Headache clusters may be separated by months or years, and it is appropriate to consider medical
certification when the cluster has cleared and treatment has ceased. Frequency of prior clusters is an
important ingredient in this evaluation.
Chronic Daily Headache
Though not an episodic disorder, chronic daily headache is mentioned here for convenience. Formerly
known by other names such as tension headache, these headaches are not incapacitating but nagging and
frequent. Therapeutic agents (barbiturate-containing analgesics, antidepressants, minor tranquilizers, etc.)
constitute the major aeromedical concern.
Operational implications:
Chronic daily headache of significant severity and requiring treatment is disqualifying for all classes of
medical certification.
Aeromedical considerations:
In addition to distraction and discomfort from the headache itself, chronic daily headache is often treated
with narcotic analgesics, antidepressants, anticonvulsants, and perhaps sedative hypnotics and minor
tranquilizers. The condition itself and the treatment thus preclude certification while these conditions
prevail. Psychological factors also commonly need attention.
Medical certification may be possible when freedom from prohibitive medication and resolution of
psychological factors have been achieved. A three to six month observation period to document resolution
of symptoms is appropriate to the issue of chronic daily headache.
Transient Global Amnesia (TGA)
This condition is characterized by abrupt onset of severe anterograde and a variable degree of retrograde
amnesia resolving in 24 hours (mean duration 4-6 hours). The individual performs normally, but asks
1 Horton’s headache: after Bayard Taylor Horton, American physician (1895-1980)
2 Horner’s syndrome: ptosis of the upper eyelid, constriction of the pupil, and anhidrosis and flushing of the affected
side of the face. After Johann Friedrich Horner, Swiss ophthalmologist (1831-1886).
ICAO Preliminary Unedited Version — October 2008 III-10-5
repetitive questions and does not record new memories. Complex functions such as building a cabinet,
putting together a bicycle, or flying an aircraft can be flawlessly performed during the event. When the
episode resolves, retrograde amnesia shrinks in time, leaving a permanent retrograde gap of an hour or
more. TGA usually occurs between ages 50-90, but it has been reported at any age, including
adolescence.
Reported precipitants of TGA include cold water immersion, physical exertion, sexual intercourse,
benzodiazepine use, medical procedures such as transfemoral angiography, and intense emotion.
Though typically an isolated event, a recurrence rate of three per cent per year over five years has been
reported. The cause is unknown, but any association between TGA and cerebrovascular disease has been
refuted by scientific evidence. Medical certification may be considered following an observation period.
Operational implications:
A diagnosis of Transient Global Amnesia is disqualifying for all classes of medical certification because
of risk of sudden impairment.
Aeromedical implications:
In many individuals with Transient Global Amnesia there is a readily identifiable proximate precipitant,
such as emotional stress, cold water immersion, or other factors.
Absent the precipitating circumstances, medical certification is appropriate following a symptom free
observation period of one year or more. Restriction to multicrew operations and non-safety-sensitive air
traffic control duties can provide an additional measure of risk mitigation.
Syncope
Syncope is defined as loss of consciousness and postural tone due to global cerebral hypoperfusion,
followed by spontaneous recovery. In near-syncope or pre-syncope, consciousness is compromised but
preserved. The condition is common, occurring in three per cent of the population. The terms vasovagal,
neurocardiogenic, neurally mediated, and neuroregulatory syncope are synonymous. In vasodepressor
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Manual of Civil Aviation Medicine 2(25)
