Benign Valsalva's maneuver-related headache: an MRI study of six cases

Cough headache is not infrequent, but there have not been any series studied with current neuroimaging techniques, and effective therapy has seldom been reported. In a large series from an outpatient clinic of a general hospital, we have studied, with MRI, eight cases of headache related to situations provoking sudden increase of intrathoracic pressure (cough, straining, stooping), similar to that elicited by a Valsalva's maneuver. One case showed hindbrain herniation and another showed isolated hydrocephalus. Symptoms did not differ between these two cases and the six cases without MRI abnormality. Initial symptoms presented between 49 and 67 years of age, and headache was of variable location and duration, mostly global and short-lasting. During a mean follow-up of 13.3 months, one patient became spontaneously asymptomatic, one improved on indomethacin, and two improved after treatment with propranolol. We propose the eponym, benign Valsalva's maneuver-related headache (as more appropriate than the equivalent "cough headache"), for cases in which headache is related to such situations and structural lesions are excluded by MRI or similar tests.