Abstract
BackgroundThe current definition of cough headache includes provocation of the symptom by Valsalva manoeuvre, and it is generally believed that all cough headache results from a sudden increase in intracranial pressure. We sought to question that presumption and to determine whether the Valsalva test might distinguish primary from secondary cough headache.MethodsWe examined 16 consecutive cough headache patients using a modified Valsalva test (exhalation into the connecting tube of a standard anaeroid sphygmomanometer to 60 mm Hg for 10 seconds). A positive response was recorded if the manoeuvre provoked headache. All patients subsequently underwent brain MRI.ResultsNone of the patients had neurological signs. Eleven had positive modified Valsalva tests. Ten were found subsequently to have posterior fossa pathologies (secondary cough headache: 8 Chiari Type 1 malformations, 2 posterior fossa meningiomas). The cough headache was relieved following surgery in all cases. One patient with a positive Valsalva test had an apparently normal brain MRI but measurements of hindbrain and posterior fossa dimensions were consistent with ‘posterior fossa crowdedness’. The remaining 5 patients had negative (4 patients) or equivocal (1 patient) Valsalva tests and normal MRI scans (primary cough headache).ConclusionsThese findings suggest that secondary cough headache results from a transient increase in intracranial CSF pressure during exertion in the presence of obstruction to normal cerebrospinal fluid dynamics. The modified Valsalva test can also determine whether tonsillar herniation found on brain MRI is symptomatic. Primary cough headache appears to be caused by a different mechanism, possibly through congestion of the orbital venous plexus in the presence of jugular venous incompetence and a reduced threshold for trigeminal sensory activation.
Highlights
The current definition of cough headache includes provocation of the symptom by Valsalva manoeuvre, and it is generally believed that all cough headache results from a sudden increase in intracranial pressure
While historical and epidemiological evidence suggests that exercise-triggered migraine, exertional headache and coital cephalalgia are almost always benign, and probably manifestations of the migraine mechanism [1], cough headache is unique among headache disorders in that it is commonly associated with intracranial pathologies, most often posterior fossa abnormalities such as Chiari malformation [1]
We have examined the hypothesis that a Valsalva test might distinguish primary from secondary cough headache
Summary
The current definition of cough headache includes provocation of the symptom by Valsalva manoeuvre, and it is generally believed that all cough headache results from a sudden increase in intracranial pressure. Most headaches are exacerbated by coughing, sneezing, straining and other exertions but some individuals experience headache exclusively with physical activities. The most common is ‘primary exertional headache’, defined under IHC2 as “a throbbing headache lasting from 5 minutes to 48 hours, occurring during physical exertion but not otherwise and not overlap between primary exertional headache and cough headache in terms of provocative activities. While historical and epidemiological evidence suggests that exercise-triggered migraine, exertional headache and coital cephalalgia are almost always benign, and probably manifestations of the migraine mechanism [1], cough headache is unique among headache disorders in that it is commonly associated with intracranial pathologies, most often posterior fossa abnormalities such as Chiari malformation [1]. The term primary cough headache (PCH) denotes patients where no relevant pathology is evident on brain imaging
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