A patient may complain of very severe, transient cranial pain on coughing, sneezing, laughing heartily, lifting heavy objects including weight lifting, stooping, and straining at stool. Pain is usually felt in the front of the head, sometimes occipitally, and may be unilateral or bilateral. As a rule, it follows the initiating action within a second or two and lasts a few seconds to a few minutes. The pain is often described as having a bursting quality and may be of such severity as to cause the patient to cradle his head in his hands, thereby simulating the headache of acute subarachnoid hemorrhage.
Most often this syndrome is a benign idiopathic state that recurs over a period of several months to a year or two and then disappears. Many decades ago, Symonds emphasized the benignity of the condition. In a report of 103 patients followed for 3 years or longer, Rooke found that additional symptoms of neurologic disease developed in only 10. The cause and mechanism have not been determined. During the headache, the CSF pressure is normal. Bilateral jugular compression may induce an attack, possibly because of traction on the walls of large veins and dural sinuses. In a few instances, we have observed this type of headache after lumbar puncture or after a hemorrhage from an arteriovenous malformation.
Patients with cough or strain headache will only occasionally be found to have serious intracranial disease; when present, particularly if a first attack, subarachnoid hemorrhage may be suspected. In other infrequent cases, this type of headache has been traced to lesions of the posterior fossa and foramen magnum, arteriovenous malformation, subdural hematoma, Chiari malformation, or tumor. It may be necessary, therefore, to supplement the neurologic examination by appropriate lumbar puncture, CT and MRI. Far more common, of course, are the temporal and maxillary pains that are caused by dental or sinus disease, which may also be worsened by coughing.
A special variant of exertional headache is “weight-lifter’s headache.” It occurs either as a single event or repeatedly over a period of several months, but each episode of headache may last many hours or days, again raising the suspicion of subarachnoid hemorrhage. The pain begins immediately or within minutes of heavy lifting. If the pain resolves in an hour or less and there is no meningismus or sign of bleeding on the CT, we have foregone lumbar puncture and angiography but have suggested that weight lifting not be resumed for several weeks. Athletes and runners in general seem to suffer exertional headaches quite often in our experience, and the episodes usually have migrainous features.
Indomethacin is usually effective in controlling exertional headaches; this has been confirmed in controlled trials. Useful alternatives are NSAIDs, ergot preparations, and propranolol. In a few of our patients, lumbar puncture appeared to immediately resolve the problem in some inexplicable way.
All manner of headache has been attributed to Chiari type I malformation (with tonsils descended at least 3 mm below the lip of the foramen magnum), but with limited justification. However, some instances of exertional and Valsalva-induced suboccipital pain can be attributed to this developmental abnormality. In the survey by Pascual and colleagues of 50 patients with Chiari type I malformations, approximately a quarter described a fairly specific pattern of pain consisting of bursting, dull, throbbing, or lancinating discomfort for seconds to far longer following Valsalva-related activities, either in the occipital or frontal region and radiating to one or both shoulders. Only the degree of tonsillar descent correlated with the presence of exertional headache and skull abnormalities such as basilar impression were not clearly associated with this type of headache. It follows that suboccipital decompressive operations for headache in this condition should be undertaken only selectively. Chiari malformation is discussed further in Chap. 37.
Headaches Related to Sexual Activity