Ask the Experts - What are the Possible Etiologies of and Treatment...
Ask the Experts - What are the Possible Etiologies of and Treatment...
The patient, an elderly male, complains of "shooting" headache usually in the right frontal area, brought on by: a) coughing, b) sneezing, or c) bending over. The pain lasts for anywhere from a few minutes to an hour. The patient was originally studied for sinus disease, and was negative. MRI of the brain without contrast did not reveal significant change.
Could this be neurological? Where do I go from here?
The term "cough headache" refers to headaches brought on by coughing, sneezing, weightlifting, bending, lifting, stooping, or straining with a bowel movement. Symptomatic or secondary cough headache can be caused by Arnold-Chiari malformations, posterior fossa tumors, platybasia, and basilar impression. In some cases, the onset occurs after a respiratory infection with cough. Rarely, internal carotid artery stenosis can cause unilateral cough headache.
Pascual and colleagues reported 17 patients with symptomatic cough headache ranging in age from 15-63 years. The headaches were bilateral in 94%, lasted seconds to days, and were described as "bursting."
Pascual and associates also described 13 patients ranging in age from 44-81 years with benign cough headaches. The headaches were bilateral in 92% and lasted seconds to 30 minutes. The pain was described as sharp, stabbing, or pulsating. By contrast, the International Headache Society criteria of 1988 require a duration of up to 1 minute. There are cases reported of brief intense pain followed by dull, aching pain that can last for hours.
In the case of your patient, let's assume that posterior fossa and cervico-medullary pathology has been excluded by the MRI. It would also be worthwhile to obtain a carotid ultrasound to exclude carotid stenosis as a cause. Evaluation by a dentist might even be helpful since some patients have resolution of the headaches after removal of abscessed teeth. If the work-up is completely negative, the headache would then best fit into the benign cough headache category. Treatments reported as effective for benign cough headache include indomethacin 25 mg to 50 mg three times a day, lumbar puncture, and methysergide.
The patient, an elderly male, complains of "shooting" headache usually in the right frontal area, brought on by: a) coughing, b) sneezing, or c) bending over. The pain lasts for anywhere from a few minutes to an hour. The patient was originally studied for sinus disease, and was negative. MRI of the brain without contrast did not reveal significant change.
Could this be neurological? Where do I go from here?
The term "cough headache" refers to headaches brought on by coughing, sneezing, weightlifting, bending, lifting, stooping, or straining with a bowel movement. Symptomatic or secondary cough headache can be caused by Arnold-Chiari malformations, posterior fossa tumors, platybasia, and basilar impression. In some cases, the onset occurs after a respiratory infection with cough. Rarely, internal carotid artery stenosis can cause unilateral cough headache.
Pascual and colleagues reported 17 patients with symptomatic cough headache ranging in age from 15-63 years. The headaches were bilateral in 94%, lasted seconds to days, and were described as "bursting."
Pascual and associates also described 13 patients ranging in age from 44-81 years with benign cough headaches. The headaches were bilateral in 92% and lasted seconds to 30 minutes. The pain was described as sharp, stabbing, or pulsating. By contrast, the International Headache Society criteria of 1988 require a duration of up to 1 minute. There are cases reported of brief intense pain followed by dull, aching pain that can last for hours.
In the case of your patient, let's assume that posterior fossa and cervico-medullary pathology has been excluded by the MRI. It would also be worthwhile to obtain a carotid ultrasound to exclude carotid stenosis as a cause. Evaluation by a dentist might even be helpful since some patients have resolution of the headaches after removal of abscessed teeth. If the work-up is completely negative, the headache would then best fit into the benign cough headache category. Treatments reported as effective for benign cough headache include indomethacin 25 mg to 50 mg three times a day, lumbar puncture, and methysergide.
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