Headaches in the Cockpit ‍: What Pilots Should Know About FAA Rules and CACI

Headaches in the Cockpit ‍

What Pilots Should Know About FAA Rules and CACI

If you’ve ever paused before checking the “headaches” box on your FAA medical application, you’re definitely not alone. Headaches are one of the most common neurologic complaints pilots report—ranging from tension headaches after a long duty day to migraines or cluster headaches. Many pilots worry that admitting to headaches will automatically ground them.

Here’s the good news: most headache disorders are FAA-acceptable, and many qualify for CACI (Conditions AMEs Can Issue) when specific criteria are met.

Why the FAA Cares About Headaches

The FAA isn’t concerned about the headache itself—it’s concerned about what’s causing it and how it could affect safety in the cockpit. Headaches can sometimes signal an underlying neurologic condition or cause distraction, visual disturbances, or incapacitation.

When evaluating headaches, the FAA looks closely at:

• Frequency and severity

• Associated neurologic symptoms

• Medication use

• Stability over time

• Impact on flight operations

It’s also important to emphasize that pilots should always talk with their doctor about headaches, especially if they are new, changing, or getting worse. Increasing frequency or severity can occasionally be a sign of a more serious condition that deserves investigation. Addressing headaches early protects not just your medical certificate, but your long-term health as well.

Common Headache Types and FAA Guidance

1. Tension-Type Headaches

Tension headaches are the most common type pilots experience. They’re usually mild to moderate, described as a band-like pressure around the head, and not associated with neurologic symptoms. Triggers often include stress, fatigue, dehydration, posture, or muscle tension in the neck and shoulders.

Medications: Acetaminophen, ibuprofen, or naproxen—provided you tolerate them well and have no side effects.

Most tension headaches can be issued at the exam without deferral. I’ll add a personal note here: I suffer from tension headaches myself. Long days, stress, and poor sleep—especially on layovers—can all contribute. What’s helped me most is being proactive. I get regular massage with a strong focus on the head and neck, which has significantly reduced both the frequency and severity of my headaches. Tight occipital and cervical muscles, often aggravated by hotel pillows, are a very real trigger for many pilots. Hydration, stretching, and muscle care can make a big difference.

2. Migraine Headaches (With or Without Aura)

Migraines may include visual aura, nausea, or light sensitivity, which understandably make pilots nervous about reporting them. However, many pilots with stable, well-controlled migraines qualify under CACI and continue flying without interruption.

The key factors are predictability, infrequency, appropriate medication use, and no in-flight incapacitation.

3. Cluster Headaches

Cluster headaches cause severe, unilateral pain around the eye or temple and may include tearing, nasal congestion, or eyelid drooping. They occur in clusters over weeks.

CACI may be possible if attacks are infrequent, stable, and treated with FAA-acceptable medications. Active or unpredictable clusters usually require deferral and further review.

FAA CACI Headache Eligibility Criteria

To qualify for CACI (for migraines and select cluster headache cases), all of the following must be met:

• No more than one episode per month

• No more than two urgent care or outpatient visits in the past 12 months

• No inpatient hospitalizations for headaches

• Diagnosis well established

• Stable and predictable headache pattern

• No progressive neurologic disease

• Normal neurologic exam between episodes

• No in-flight incapacitation

• Pilot does not fly during active symptoms

• Medications are FAA-acceptable and well tolerated

If all criteria are met, the AME can often issue at the exam without FAA deferral.

Medications Allowed Under CACI

Preventive medications (stable dose, non-sedating, ground trial completed):

• ACE inhibitors (ACE-I)

• Angiotensin receptor blockers (ARB)

• Beta blockers

• Calcium channel blockers (CCB)

• CGRP antagonists (preventive use only)

Abortive medications (no-fly times apply):

• Triptans: 24-hour no-fly

• Eletriptan (Relpax) & Frovatriptan (Frova): 72-hour no-fly

• Metoclopramide (Reglan): 36-hour no-fly

• Promethazine (Phenergan): 96-hour no-fly

• CGRP abortives (Ubrelvy, Nurtec): 48-hour no-fly

Ground trials are required, and pilots must never fly during active headache symptoms.

Medications Typically Not FAA-Acceptable

• Narcotics or opioids

• Barbiturates

• Sedating or cognition-impairing drugs

• TCAs, gabapentin, lacosamide, lamotrigine, lasmiditan, pregabalin, topiramate, valproic acid

Always confirm with your AME and reference FAA.gov for the most current guidance.

When Headaches Require Deferral

An AME must defer if there is:

• More than one episode per month

• Increasing frequency or severity

• Abnormal neurologic exam

• Seizure-like activity or loss of consciousness

• Use of disallowed medications

• Excessive urgent care or ER visits

• Any history of in-flight incapacitation

Further evaluation—often with neurology consultation—is required.

Bottom Line for Pilots

• Tension headaches: almost always issuable

• Migraines: often CACI-eligible if stable and controlled

• Cluster headaches: possible, but more restrictive

Early medical evaluation, stable treatment, and open conversations with your AME can prevent unnecessary delays—and keep you flying safely and confidently.

Have more questions? I will be guest speaking at SUN 'n FUN in April and would love to see you there!

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