Spontaneous Low Cerebrospinal Fluid Pressure Syndrome Can Mimic Primary Cough Headache

Primary Cough Headache

PURPOSE OF REVIEW

In this review article, we summarize the most recent findings and observations in patients experiencing primary cough headache.

RECENT FINDINGS

Recent studies draw attention to further characterization of patients with primary cough headache in a pulmonology clinic. There have also been recent case studies describing new therapy considerations, including noninvasive vagus nerve stimulation and lumbar punctures. Primary cough headache has been a recognized entity since as early as 1932. Patients generally report a sudden onset, sharp headache lasting a few hours that is precipitated by Valsalva maneuver or coughing. It remains an uncommon diagnosis, and secondary causes are crucial to rule out with imaging studies. Additionally, there can be an overlap with other primary headache disorders such as primary exercise headache and headache associated with sexual activity, thus requiring a detailed history. Many hypotheses exist regarding the pathophysiology including relative pressure gradients and a crowded posterior fossa. Generally, patients are responsive to indomethacin, but more recent case reports have suggested benefits of other medications and procedures that may offer patients an alternative option, including vagus nerve stimulation, lumbar punctures, and beta blockers. Future case series and studies should focus on management of these patients, with a specific focus on individuals who do not tolerate indomethacin.

Spinal cerebrospinal fluid leak in the context of pars interarticularis fracture

Background

Spinal cerebrospinal fluid (CSF) leak can lead to intracranial hypotension and is an important differential diagnosis to consider in patients with sudden-onset chronic daily headaches. Pars interarticularis (PI) fracture is a potential rare cause of suspected spinal CSF leak.

Methods

This is a retrospective case series of 6 patients with suspected spinal CSF leak evaluated between January 2016 and September 2019. All patients received a magnetic resonance imaging (MRI) of the brain with and without gadolinium, MRI whole spine and full spine computed tomography (CT) myelogram. Targeted epidural patches with fibrin sealant were performed. Treatment response at return visit (3 months post-patch) was documented.

Results

Six patients (4 females, 2 males) were diagnosed with a suspected spinal CSF leak and PI fracture. Mean age at the time of headache onset was 39 years old, and a range from 32 to 50 years old. Mean time to targeted epidural patches with fibrin sealant was 4.5 years. All 6 patients had PI fractures identified on CT myelogram and received targeted epidural patches with fibrin sealant at the site of the PI fracture. All patients had significant improvement in their headache intensity.

Conclusion

Our study highlights: 1) the importance of PI fracture as a possible culprit of suspected spinal CSF leak in patients with intracranial hypotension; 2) the added benefit of CT imaging for detecting bony abnormalities such as fractures in patients with intracranial hypotension; and 3) the successful treatment of suspected spinal CSF leak when targeting the fracture site.

Modified Valsalva test differentiates primary from secondary cough headache

I suppose that the patient number 14, reported in the article of RJ Lane et al. on “Modified Valsalva test differentiates primary from secondary cough headache ”in a recent issue of your esteemed journal, was probably suffering from spontaneous intracranial hypotension syndrome (SIH) caused by cervical manipulation.

Headache associated with cough: a review

Headache only triggered by coughing is a rather uncommon condition. The aim of the present review is to present an overview of the diagnosis, clinical characteristics, pathophysiology and treatment of both primary and symptomatic cough headache and discuss other relevant headache disorders affected by coughing. The diagnosis of primary cough headache is made when headache is brought on and occurs only in association with coughing, straining or a Valsalva manoeuvre and in the absence of any abnormalities on neuro-imaging. In case an underlying pathology is identified as a cause of the headache, the diagnosis of symptomatic cough headache is made. The vast majority of these patients present with a Chiari malformation type I. Other frequently reported causes include miscellaneous posterior fossa pathology, carotid or vertebrobasilar disease and cerebral aneurysms. Consequently, diagnostic neuroimaging is key in the diagnosis of cough-related headache and guides treatment. Besides primary and symptomatic cough headache, several other both primary and secondary headache disorders exist where coughing acts as a trigger or aggravator of headache symptomatology.

Treatment of miscellaneous idiopathic headache disorders (Group 4 of the IHS classification)--report of an EFNS task force

BACKGROUND AND PURPOSE

Certain miscellaneous idiopathic headache disorders, which are regarded as entities, are grouped in Chapter 4 of the International Classification of Headache Disorders. Recent epidemiological research suggests that these headache disorders are underdiagnosed.

OBJECTIVES

To give expert recommendations for the different drug and non-drug treatment procedures of these different headache disorders based on a literature search and on consensus of an expert panel.

METHODS

All available medical reference systems were screened for all kinds of clinical studies on these headache disorders. The findings in these studies were evaluated according to the recommendations of the EFNS resulting in level A, B or C recommendations and good practice points.

RECOMMENDATIONS

For all headache disorders, acute and prophylactic drug treatment is recommended based on case series and on expert consensus. Furthermore, recommendations for the differential diagnoses are given because these headache disorders can also present with a symptomatic form. The most effective drug for the majority of these headache disorders is indomethacin, mostly applied as long-term or short-term prophylaxis.

A case of idiopathic low CSF pressure headache presenting as cough headache

Idiopathic low cerebrospinal fluid (CSF) pressure headache is considered to be one that worsens within 15 min of sitting-up or standing-up, accompanied by at least one of the following: neck stiffness, tinnitus, hypacusia, photophobia and nausea. Several reports suggest that a substantial number of idiopathic low CSF pressure cases do not present typical clinical symptoms and that a considerable clinical variability exists. We report the case of an idiopathic low CSF pressure presenting as a cough headache.

Diagnostic testing for chronic daily headache

Primary chronic headaches of long duration include chronic migraine, chronic tension-type headache, new daily persistent headache, and hemicrania continua. This article reviews the utility of neuroimaging and other testing for diagnosis of these headaches. The presentation and diagnosis of the many secondary headaches that can mimic primary headache types are also discussed, including arteriovenous malformations, spontaneous intracranial hypotension, neoplasms, pseudotumor cerebri, cervical artery dissections, cerebral venous thrombosis, Chiari I malformation, and temporal arteritis. Although the yield of diagnostic testing is low, serious pathology as a cause of chronic headaches can be easily overlooked.

Uncommon primary headaches

PURPOSE OF REVIEW

The new International Classification of Headache Disorders was recently published by the International Headache Society. Several uncommon primary headaches, including some new clinical entities (e.g. hypnic headache), were included in the section on 'Cluster headache and other trigeminal autonomic neuralgias' and 'Other primary headaches'. The recent classification offers an interesting opportunity to evaluate the clinical role and to discuss the mechanisms of some of the more relevant uncommon primary headaches.

RECENT FINDINGS

Due to the low incidence of these uncommon headache forms, their diagnostic criteria, pathogenetic mechanisms and therapy are still debated. Differential diagnosis versus secondary headaches is also a crucial issue. In this review, some of the most important uncommon primary headaches are discussed in light of the most recent contributions to the literature.

SUMMARY

The review focuses on the update of the main uncommon primary headaches, intending to clarify some controversial points and to indicate some headlines for further research.