The Clinical Syndrome
Cough headache is a term used to describe headaches triggered by coughing and other activities associated with a Valsalva maneuver, such as laughing, straining at stool, lifting, and bending the head toward the ground ( Fig. 7.1 ). Clinicians have identified the following two types of cough headache:
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Benign primary cough headache
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Symptomatic cough headache
Initially, both types of cough headache were thought to be related to sexual and exertional headaches, but they are now considered distinct clinical entities. A strong male predilection is seen for benign cough headache and no gender predilection for symptomatic cough headache.
Signs and Symptoms
Patients suffering from cough headache present differently depending on the type of cough headache experienced. Each clinical presentation is discussed.
Benign Cough Headache
Benign cough headache is not associated with obvious neurological or musculoskeletal disease. More than 80% of patients with benign cough headache are males, in contradistinction to symptomatic cough headache, in which no gender predilection is seen. The onset of benign cough headache is abrupt, occurring immediately after coughing or other activities that cause a Valsalva maneuver. Although the intensity of pain is severe and peaks rapidly, it lasts only seconds to minutes. The character of the pain associated with benign cough headache is splitting or sharp, and the pain is in the occipital region bilaterally and occasionally the vertex of the skull. No accompanying neurological or systemic symptoms are seen, as with cluster and migraine headaches. The age of onset of benign cough headache is generally in the late fifth or sixth decade of life. If such headaches occur before age 50, there should be strong clinical suspicion that the patient either has symptomatic cough headache or a pathological condition in the posterior fossa, such as Arnold-Chiari malformation or tumor. Tumors of the foramen magnum also may mimic the presentation of benign cough headache even if no neurological symptoms are present.
Symptomatic Cough Headache
Symptomatic cough headache is almost always associated with structural abnormalities of the cranium, such as Arnold-Chiari malformation I and II or intracranial tumors ( Fig. 7.2 ). The symptoms associated with symptomatic cough headache are thought to be due to herniation of the cerebellar tonsil through the foramen magnum into the space normally occupied by the upper portion of the cervical spinal cord. Similar to benign cough headache, the onset of pain associated with symptomatic cough headache is abrupt, occurring immediately after coughing or other activities that cause a Valsalva maneuver. Although the intensity of pain is severe and peaks rapidly, it lasts only seconds to minutes. In contrast to benign cough headache, associated neurological symptoms may be present, including difficulty swallowing, faintness, and numbness in the face and upper extremities. These associated symptoms should be taken very seriously because they are indicative of increased intracranial pressure and herniation of the intracranial contents.
The character of the pain associated with symptomatic cough headache is splitting or sharp, and pain is in the occipital region bilaterally and occasionally the vertex of the skull. The age of onset of symptomatic cough headache is generally in the third decade of life, although, depending on the amount of neurological compromise, it may occur at any age. In contrast to benign cough headache, which occurs predominantly in men, symptomatic cough headache occurs with equal prevalence in both genders.
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