Primary Cough Headache Responsive to Topiramate

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.

Primary Cough Headache: A Case Report

Primary cough headache (PCH) is an uncommon condition characterized by episodes of sudden onset, bilateral headaches typically lasting from a second to two hours. Headaches are notably associated with Valsalva maneuvers such as coughing or straining but not a prolonged physical exercise in the absence of intracranial abnormalities. We report an unusual presentation of PCH in a 53-year-old female suffering from episodes of severe sudden-onset headaches that lasted several hours. The headaches were initially precipitated by coughing as is typical with PCH but were unusual in the way the triggers for the episodes evolved. Headaches began occurring without any association of Valsalva maneuvers and ultimately occurred with no discernible trigger. The patient initially came to the cardiologist's office who then referred her to a neurologist for further evaluation. The neurologist initially prescribed methylprednisolone tablets, primarily to suppress the cough. Magnetic resonance imaging, magnetic resonance angiography (MRA) of the brain, and a head CT scan were then performed to rule out possible secondary causes such as a mass, intracranial bleed, aneurysms, or other vascular anomalies. The neurologist prescribed indomethacin and topiramate four and nine days after diagnosis of PCH, respectively. After five days, the beta blocker metoprolol tartrate was prescribed as the patient's blood pressure was rising significantly in correlation to the headaches. The above treatment was effective in limiting the intensity and duration of the headaches and the symptoms resolved after four weeks. This case contributes towards the understanding of the potential evolution of PCH presenting with triggers unassociated with Valsalva maneuvers and ultimately occurring with no known trigger as well as providing an example of PCH with an unusually long duration.

Uncommon (Group 4.0) Primary Headaches: Less Familiarity and More Missed Diagnosis

Background

Other primary headaches make up group 4.0 of the International Classification of Headache Disorders third edition (ICHD-3). This group includes a clinically varied group of headache entities whose pathophysiology is not well understood and whose treatments are based on open-label reports.

Objective

To review and update the uncommon primary headaches included under group 4.0 in ICHD-3.

Methods

We reviewed the headache disorders listed under group 4.0 of ICHD-3 for the clinical features, diagnostic criteria, and management, and described recent updates of these relatively rare disorders.

Results

The entities included in this group have a characteristic presentation in practice. Some of them are activity-related and can be provoked by Valsalva maneuver (primary cough headache), some by prolonged exercise (primary exercise headache), and some by sexual excitation (primary headache associated with sexual activity); primary thunderclap headache has also been included here because all the above-listed entities can sometimes present in thunderclap fashion too. Two of the entities in this group 4.0 are linked to direct physical stimuli viz. cold stimulus headache and external pressure headache. Also included in this group are primary stabbing headaches and nummular headaches that are presumed to be due to the involvement of the terminal branches of the sensory nerves supplying the scalp and are, therefore, termed "epicranial headaches." Hypnic headache syndrome and new daily persistent headache are included here as "miscellaneous headaches" because we still do not know enough about their causation.

Conclusion

The headache disorders included under group 4.0 in ICHD-3 are uncommon, heterogeneous entities, which may pose diagnostic and management challenges to the physicians. The diagnosis may be missed owing to a lack of familiarity.

Cough, exercise, and sex headaches

Cough, exercise, and sex headaches are underrecognized distinct but related syndromes, triggered by rapid rises in intra-abdominal pressure. All may occur as a manifestation of a possible underlying, symptomatic etiology, and additional diagnostics should typically be pursued to rule out serious causes. Cough headaches may be more common in certain subgroups or settings. Based on recent epidemiologic data, exercise-related headache may be more common than previously thought. There is no evidence that different pain types in sexual headaches are distinct from a pathophysiologic standpoint. Each of these headache syndromes is reported to be responsive to indomethacin.

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.

Focus on therapy of the Chapter IV headaches provoked by exertional factors: primary cough headache, primary exertional headache and primary headache associated with sexual activity

Primary cough headache, primary exertional headache and primary headache associated with sexual activity are distinct entities, even though they share several features: acute onset, the absence of structural brain disease and exertional factors as precipitating events. In this short review, we illustrate the possible treatment strategies on the basis of information collected from a systematic analysis of the international literature.

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.