Nutcracker syndrome mimicking new daily persistent headache: A case report

Compression of the duodenum and left renal vein between the aorta and superior mesenteric artery usually leads to symptoms of proximal bowel obstruction or hematuria and, more rarely, nonspecific mild headaches.

A young woman presented with new daily persistent headache refractory to numerous pharmacological treatments, onabotulinumtoxinA, nerve blocks, and occipital nerve stimulation. Following several years of daily severe headache, worsening abdominal pain and intolerance for food intake led to the discovery of aortomesenteric compression. Surgical treatment gave prompt improvement in gastric symptoms but also essentially resolved the headache.

This is the first description of new daily persistent headache in association with aortomesenteric compression as well as marked improvement of headache following aortomesenteric decompression. In patients with new daily persistent headache and orthostatic symptoms one may consider a differential diagnosis of Nutcracker syndrome, especially in patients with comorbid hypermobility syndromes, hematuria or gastric symptoms.