Posture-related cough headache and orthostatic drop in lumbar CSF pressure

Abstract

Sirs: Primary cough headache (PCH) is an uncommon headache disorder marked by a sudden bilateral short-lasting pain precipitated by coughing in the absence of any intracranial disorder [1, 2]. In some patients with PCH, Symonds reported that vertical posture precipitated pain brought on by coughing [3]. We have seen two such patients (a 48-year-old man and a 31-yearold woman) with headaches lasting 1–10 min that were only triggered by coughing when the patients assumed a vertical posture, in whom we have also observed orthostatic drops in their CSF pressures. Neurological examination did not show any deficits. Contrast-enhanced head and spine MRI, and CSF examination findings were all normal. In these patients and in 25 controls (average age: 40.2 ± 7.7 years; 15 women and 10 men) none of whom had a history of headache or structural brain lesion, we recorded the lumbar cerebrospinal fluid (CSF) opening pressure at rest and during three to five coughs, in lateral decubitus, sitting and upright positions. In our patients lumbar CSF opening pressure recorded in lateral decubitus was within normal values (pressure of 153 and 164 mm H2O, respectively). In the sitting position lumbar CSF pressure was higher (330 and 310 mm H2O, respectively) than in lateral decubitus. In both positions a bout of coughing did not induce headache. Surprisingly, when the patients assumed the upright posture their lumbar CSF pressures dropped (160 and 165 mm H2O, respectively) compared with the values recorded in the sitting position, and a bout of coughing induced severe pain at the vertex. In the control group, postural changes (sitting and upright positions) always increased CSF lumbar pressure with more elevated value recorded in the upright posture (Figure). Coughing always increased CSF pressure regardless of positions, both in controls and in patients. The present findings demonstrate that our patients had posture-related cough headaches. Consistent with this observation, in the landmark paper entitled “Cough headache” Symonds [3] described four patients with PCH that was induced by the patients being in upright positions, whereas the patients could cough without pain when they were lying down. The Symonds’ study and the present cases suggest the possibility that in the minority of patients with cough headaches, the pain brought on by coughing can occur only in association with the vertical posture. In addition, our patients had orthostatic drops in their CSF pressures. This finding was never observed in controls in whom vertical posture always elevated their CSF pressures. As our patients had orthostatic headaches precipitated rather than aggravated by coughing, and they did not have imaging abnormalities of intracranial hypotension or low supine CSF pressures, spontaneous intracranial hypotension and abnormally low volume of CSF may be excluded [4–7]. Of note, some authors have recently demonstrated that patients with orthostatic headaches without LETTER TO THE EDITORS