A cough headache can either be primary (idiopathic) or secondary to another disease condition. In both types, individuals experience a sudden onset headache that is associated with coughing, and the Valsalva maneuver. Neuroimaging is an important tool in excluding underlying pathology.
A cough headache (CH) is a rare diagnosis. It is described as a headache that lasts between one second and thirty minutes, as a result of coughing or other actions that cause an acute increase in intra-abdominal pressure, such as the Valsalva maneuver, straining when passing stool, lifting heavy weights and sneezing. Headaches of longer duration, up to two hours, have been reported [1]. All individuals have a 1% risk of suffering from cough headaches during their lifetime [2]. The disease prevalence in specialized headache clinics is similar [3]. In terms of distribution, men are more affected by CH than women, and the diagnosis is usually made after the fourth decade of life.
CH is classified into primary and secondary (also referred to as symptomatic CH), as described by the International Headache Society (IHS) [4]. In primary CH, there is no identifiable cause for the headache. Moreover, primary CH is benign [5]. The typical characteristics of a primary CH are sudden onset of bilateral pain in the frontotemporal or posterior regions of the head, with varying intensities, sometimes described as explosive [1]. Less common presentations include a unilateral headache and toothache [6] [7]. Features such as nausea and vomiting, as well as photophobia and phonophobia, which are commonly experienced in migraines, are not typical of CH.
Secondary CH occurs in response to an existing condition. Secondary CH is, in the majority of cases, caused by the Chiari malformation, type I. Patients with underlying pathology often exhibit a range of other symptoms, besides the headache.
It is assumed that the increase in abdominal pressure in primary CH increases venous pressure and thus intracranial pressure, culminating in CH. A similar mechanism has been proposed for secondary CH. Another hypothesis for primary CH is that there is overcrowding of the posterior cranial fossa [8]. In both classifications, the pathophysiology is not clearly understood.
It is important to note that primary CH is a diagnosis of exclusion, necessitating the investigation and exclusion of other possible causes of a headache.
As a result of the possibility of a causative disease, which is the case in about 50% of patients with cough headaches, radiological investigations have to be carried out in order to rule them out. Alternative causes of CH include posterior and anterior fossa tumors, Chiari malformation, acute sphenoid sinusitis, intracranial cysts, subdural hematoma, cerebral aneurysms, and brain metastatic lesions [1] [9]. Furthermore, other headache conditions exacerbated by coughing may be present. Neuroimaging is thus employed, of which the modality of choice is magnetic resonance imaging (MRI). It is required for diagnosis, and serves as a guide for further treatment plans.