title: Pathophysiology of headache associated with cough in patients with Chiari I malformation.
abstract: OBJECTIVE
  The aim of this study was to evaluate the pathophysiology underlying headache associated with cough in patients with Chiari I tonsillar abnormality. The authors hypothesized that peak intrathecal pressure during coughing is higher in patients with headache aggravated by cough than in patients without or in healthy volunteers. In addition, the authors evaluated the use of intrathecal pressure during cough as a means of assessing obstruction to the free flow of cerebrospinal fluid (CSF) at the craniocervical junction.
  
  
  METHODS
  Twenty-six adult patients with Chiari I malformation and syringomyelia, four adult patients with Chiari I malformation without syringomyelia, and 15 healthy volunteers were prospectively studied. Testing before surgery included the following: 1) clinical evaluation for the presence of headache associated with cough; and 2) evaluation of lumbar subarachnoid pressure at rest, during three to five coughs, while performing the Valsalva maneuver, during jugular compression, and after removal of CSF. Patients underwent suboccipital craniectomy, C-1 laminectomy, and duraplasty. Testing was repeated 6 months after surgery.
  
  
  CONCLUSIONS
  Peak intrathecal pressures during cough and at baseline were elevated in patients with headache associated with cough compared with either patients without headache or healthy volunteers. After surgery, intrathecal pressures during cough were significantly lower than preoperative values and headache aggravated by cough was resolved partially or completely. Headache linked to coughing in patients with Chiari I malformation is associated with sudden increased intrathecal pressure caused by obstruction to the free flow of CSF in the subarachnoid space.
authors.affiliation: Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892-1414, USA.
authors.forename: Charles A
authors.initials: CA
authors.lastname: Sansur
authors.forename: John D
authors.initials: JD
authors.lastname: Heiss
authors.forename: Hetty L
authors.initials: HL
authors.lastname: DeVroom
authors.forename: Eric
authors.initials: E
authors.lastname: Eskioglu
authors.forename: Robert
authors.initials: R
authors.lastname: Ennis
authors.forename: Edward H
authors.initials: EH
authors.lastname: Oldfield
mesh_terms: D000328:Adult; D001139:Arnold-Chiari Malformation / Q000150:complications* / Q000601:surgery; D015170:Cerebrospinal Fluid Pressure; D003371:Cough / Q000209:etiology* / Q000503:physiopathology; D004388:Dura Mater / Q000601:surgery; D006261:Headache / Q000209:etiology* / Q000503:physiopathology*; D006801:Humans; D009460:Neurologic Examination / Q000379:methods; D011184:Postoperative Period; D012016:Reference Values; D013346:Subarachnoid Space / Q000503:physiopathology; D014636:Valsalva Maneuver