Existential crisis, give up racing?

[Samus]

@DingoDongo

Pretty much since my early 40s. 1 beer (~5-6% ABV) would be fine if I took care to make sure I was well hydrated and ate something after, but anything above that and I’d be dealing with an all-day headache that wouldn’t respond to pain relievers on top of a night of poor sleep. Sometimes the hangover would start before bedtime. My PCP at the time (since retired) did a blood draw, and nothing popped up as unusual. FWIW, my hangover symptoms line up pretty well with migraine symptoms, but I never received a diagnosis for it. PCP said “maybe it is” and to avoid doing the things that triggered the symptoms and that was that.

My concern would be that this is all downstream of cirrhosis or something else liver-related, but I’m guessing your LFTs were normal back then if your PCP got labs done.

There’s actually a connection between alcohol and exercise intolerance—aldehyde stress (a type of oxidative stress). There could be something wrong with your ability to metabolize aldehydes. It’s more common for this to be a genetic defect, but it can also be acquired. Are you on any disulfiram-like medications? You could also do an ethanol skin patch test to see if you have an issue with aldehyde metabolism.

ROS (reactive oxygen species), like aldehydes, are generated when you workout. More time, more intensity, and more heat will increase the amount of ROS generated from exercise. If you have some kind of issue with aldehyde metabolism, your post-exercise symptoms could feel like a hangover because it is essentially a hangover (aldehyde build up).

[DingoDongo]

Okay, that’s really interesting. And not very surprising, considering I was what I would characterize as a heavy drinker for quite a while. Shortly after I quit, there were a couple times I sugar-binged myself into a hangover, which kind of supports a weakened ability to metabolize aldehydes. I’ll see if I can borrow a couple mL of vodka from a friend and do the skin patch test.

Thank you.

[Samus]

@DingoDongo

And not very surprising, considering I was what I would characterize as a heavy drinker for quite a while.

With that piece of information it seems far more likely that the liver is in play here. Good on you for stopping when you did.

Massive disclaimer: the following is extrapolation based on known relationships between exercise and liver disease on oxidative stress. As far as I can tell, there isn’t much in the way of studies for your particular case. Alcohol-induced impairment of aldehyde metabolism does not seem well-studied; lots of papers on alcohol-related liver disease, but the number of people with ALD who are attempting more than recreational exercise is going to be very small… not seeing any studies on this.

Regardless, I do suspect that your alcohol intolerance and your post-workout “hangovers” are related. Alcohol intolerance is largely an issue with not being able to deal with oxidative stress. And if there is a particular factor of exercise that increases with duration, intensity, and heat… it’s oxidative stress.

Two hypothetical pathways here involving impaired ability to deal with oxidative stress:

1. Dysfunctional aldehyde metabolism via some kind of epigenetic factors. Heavy drinking can lead to acquired dysfunction of this pathway, but it may not be related to dysfunction of the enzyme itself.
2. Impaired liver function due to alcohol-related liver damage (fibrosis/cirrhosis, mitochondrial damage, chronic inflammation). The liver is the major producer and central regulator of antioxidants. Your aldehyde metabolism could be working properly, but you could have less metabolic reserve to maintain overall redox balance. You’re good during most shorter exercises, but once the ROS generation reaches a certain point (via length, intensity, heat), your liver can’t keep up. This etiology implicates far more than aldehyde metabolism, but also the glutathione system, and a myriad of antioxidant enzymes.

Or both. #2 is going to be way more likely, stats-wise. I’d talk with your PCP about your history and see if you can get your labs drawn up for signs of alcohol-related liver disease and that whole differential (did alcohol cause the damage or was it something else that nuked your ability to tolerate the alcohol?). That would be the priority. The ethanol skin patch doesn’t mean much if negative, would be super interesting if positive.

Something you could try is supplementation of antioxidants to see if your symptoms improve. There’s mixed evidence antioxidant supplementation can help with a variety of liver diseases. That said, the end results measured were like all cause mortality, fibrosis, etc, not adverse reactions to exercise. I don’t see a major downside. Vitamin E, Vitamin C, and NAC are common interventions in these studies. All have a good safety profiles but of course [talk to your doctor if you have any contraindications disclaimer]. If you notice improvement, your symptoms might be ROS-related. If you don’t notice anything, not much can be read from that.

And before a bunch of other cyclists start thinking “oh, should I be supplementing a bunch of antioxidants too?” Probably not? You actually DO want some amount of oxidative stress from exercise for a hormetic response (a lot of poison is bad, but a little poison can be adaptive). There’s a decent amount of debate over whether antioxidant supplementation hinders athletic training stimulus. However in @DingoDongo’s case, some kind of impaired of antioxidant response could be pushing rigorous exercise into the “lotta poison bad” category.

As a final note, exercise has generally been found to be a positive intervention for improving ALD outcomes… however the amount of exercise studied is going to be more “we got sedentary people to do an 30-60mins of light cardio” not “3+ hours bike rides in the sweltering heat.”

[lstrong]

I think that it is hard to draw a connection between your hangover issues and your exercise issues. The physiology of hangovers is simply not fully understood.

My concern is that fatigue and exercise intolerance can be a presentation of heart disease. Over the years, I have seen a number very high-level athletes like you who have developed hardening of the arteries or an issue with the heart muscle called cardiomyopathy. Here are two common pitfalls in medicine: the first is to assume that an endurance athlete can not have heart disease. The second is to assume that the absence of chest pain rules out heart issues.

In addition to the basic blood work that people have recommended, you should have a cardiac workup to be sure you do not have coronary artery disease, heart valve problems, or a heart muscle problem. An Exercise tolerance test combined with an echocardiogram, called a “stress echo”, would be ideal for looking at the health of your heart.

I don’t mean to be a fear monger , but you really ought to get this checked out. Testing will probably be normal, but If it’s not, it could save your life.

[DingoDongo]

It’s a good point. I have a family history of high blood pressure and stroke, so I’ve been pretty proactive on keeping on top of heart stuff, though it has been probably 10 years since I did a stress test and echocardiogram. I’m going to add that to my to do list.

[DingoDongo]

The antioxidants seem like a pretty easy thing to try out and we still have a good 3-4 weeks of the worst of the worst hot weather.

I’ve sent a message through my portal to my PCP if we can update my blood work with my drinking past in mind.

I did the skin patch test and it came up negative, but not surprising given the relative rarity of the condition.

My previous PCP did say that he suspects my non-alcohol “hangovers” are related to my liver function and said that it would likely improve with time, but wasn’t specific beyond that, understandably. I’ll just keep rolling along and keep it easy during the hottest weather and try to narrow down the possibilities with my PCP.

[Samus]

@DingoDongo

The antioxidants seem like a pretty easy thing to try out

Yeah, I think so! From my brief survey, the studies on specifically hangover symptom relief with antioxidant supplementation have been mixed, leaning negative. Mixed results for various liver pathologies. Some of the better results are for non-alcoholic fatty liver disease. Most of the studies I’ve seen for antioxidant supplementation for alcohol-related pathologies are negative, but these are almost all severe cases on the brink of death where all cause mortality is getting measured and there’s no guarantee of abstinence from the participants.

But it’s super trivial to give it a try and see what happens in your n = 1.

@DingoDongo

My previous PCP did say that he suspects my non-alcohol “hangovers” are related to my liver function

If this is the case, think about that “hormetic effect” curve. Anything eliciting a “hangover” might be maladaptive (dose of ROS is too high).

I did a bit of digging and found that heavy alcohol use can significantly alter the heat shock response and expression of HSPs. But most of the studies are super low-level; I wasn’t able to get much in the way of “big picture” implications from it. (And I kinda doubt we’re at a point where the implications are understood.)

@lstrong

The physiology of hangovers is simply not fully understood.

It’s not. But I’m also not seeing anyone questioning the basic premise that oxidative stress plays a role. The exact mechanisms and specific pathways are still being worked out. No magic hangover cures yet.

@lstrong

My concern is that fatigue and exercise intolerance can be a presentation of heart disease.

I would second this. Especially if there’s suspicion of liver damage. Or known liver damage reading between the lines of what the PCP said?

[DingoDongo]

I almost forgot about this one. Figured I’d throw in an update that might be informative for anyone else in this situation. Blood test for liver function and general health, glucose monitor for a month (one blood test indicated low levels), ekg, and an echocardiogram indicated no cause. A pro bike fit made no improvement. I heard from a friend who experienced very similar symptoms and that lead to me getting a cervical x-ray which indicated degenerative changes in C5-C6 and C6-C7 with mild retrolisthesis on C5-C6. It took that for me to realize just how much neck pain I had been completely ignoring, for at least 3-4 years, maybe more.

The cervical stuff is about the closest I came to an answer. I had a 4 hour gravel race shortly after the x-ray results and quickly converted my Cutthroat to use Surly Moloko bars and shorted my reach. I even went pretty easy on my pace and was mindful of hydration and nutrition, I still got a migraine. I’ve been riding easy since then and haven’t had a reoccurrence. I’m looking at converting my CX racer to use Jones 2.5 Loop bars. I miss training and racing, but I think I like not having migraines more. I think I’ve been on the trainer twice since October. There’s a secret clock somewhere ticking down to when I buy my first Rivendell. That’s all!

[lokerola]

@DingoDongo

There’s a secret clock somewhere ticking down to when I buy my first Rivendell.

Nothing wrong with a Rivendell. You’ll need a subscription to The Radavist, jean shorts, and a killer handlebar mustache as well! I kid, I kid.

It’s great you found what appears to the root cause of the migraines. They are absolutely no joke and I would do anything to relieve the pain of a migraine, including hanging up my bike if it meant relief.

Good luck with your continuing health journey.

[DingoDongo]

Oof! I’m already a paid subscriber to The Radavist.

[lokerola]

You’re already on the way!

[Crouch83]

I’m late to the discussion, but I just found this thread. I’m also in my 40s and had some scary physical symptoms come up last year and linger for a few months. They were different from yours but also involved a headache. When my symptoms first presented, I ended up in the ER. All tests they performed were clear and the bloodwork was all “normal”. I went to my PCP and he conducted most of the same blood tests…which still returned normal ranges. He attributed mine to an unknown virus and said it should clear up on its own. It didn’t, and my PCP was unwilling to help further. I sought out a different Dr. who was willing to help me find an answer. He ordered scans and checked for things in my bloodwork that were not standard and had not been checked. Through these tests, he was able to identify certain vitamins that I was low in and a gene that has a mild mutation. I’ve been symptom free for a few months since I started the treatments & supplements he recommended.
Everyone is different, but I would encourage you to continue to seek answers if you aren’t improving. At our age, we should have many more years of being able to ride hard and race if we want.

[JJ20]

This just popped up in my feed and I’m having a lot of the same symptoms. I’m curious, what is your overall life stress like?

[DingoDongo]

I have a check in with my PCP coming up and I’ll ask if any of the blood tests brought up any deficiencies and what his thoughts are. But, yeah, despite my comments earlier, there is still a part of me that isn’t ready to give up. The winter and spring are going to be about finding a cockpit setup or even frame geometry that puts me in a position that eliminates the effects of the cervical stuff. If I’m successful, then I’ll see what happens when I push the intensity. While I was cautioned against relying on it regularly, the migraine abortive I was prescribed works well and will help if/when I push it too far and don’t want to be down for the count for a dozen hours.

Thanks for the insight.

[DingoDongo]

It’s so subjective, it’s hard to say. I’d self-rate my stress as medium low. Work is the biggest source of stress/anxiety in my life, but can be managed when I have my act together and it rarely ever comes home with me. My general level of stress and anxiety doesn’t seem to be throwing up any red flags with my PCP, which is about the most objective measure as I can think of.