Cough headache

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By Christopher J Boes MD, Manjit S Matharu PhD MRCP, Peter J Goadsby MD PhD, and Stephen D Silberstein MD

In this clinical article, Dr. Christopher Boes of the Mayo Clinic in Rochester, Minnesota and Drs. Manjit Matharu and Peter J Goadsby of the Institute of Neurology and the National Hospital for Neurology and Neurosurgery in London, England discuss the clinical manifestations, etiology, differential diagnosis, diagnostic evaluation, and management of cough headache. In this update, 2 recent, large prospective studies of primary cough headache patients are reviewed. Morphometric MRI studies that have shed new light on the etiology of primary cough headache are summarized, and evidence that CSF leaks may present as cough headache without an orthostatic component is presented. Although indomethacin is typically used to treat primary cough headache, the authors discuss other treatment options, including topiramate.

Key points

  • Primary cough headache is typically bilateral, of sudden onset, lasts less than 1 minute, and is precipitated rather than aggravated by coughing.
  • Primary cough headache can be triggered by other sudden Valsalva maneuvers, but it is not typically triggered by sustained physical exercise.
  • Every patient presenting with cough headache should have an MRI of the brain to rule out a posterior fossa lesion. The MRI should be done with gadolinium looking for pachymeningeal enhancement because headache secondary to spontaneous leak can present as cough headache alone, with no orthostatic component.
  • Indomethacin is the de facto preventive drug of choice for primary cough headache.