title: Modified Valsalva test differentiates primary from secondary cough headache.
abstract: BACKGROUND
  The current definition of cough headache includes provocation of the symptom by Valsalva manoeuvre, and it is generally believed that all cough headache results from a sudden increase in intracranial pressure. We sought to question that presumption and to determine whether the Valsalva test might distinguish primary from secondary cough headache.
  
  
  METHODS
  We examined 16 consecutive cough headache patients using a modified Valsalva test (exhalation into the connecting tube of a standard anaeroid sphygmomanometer to 60 mm Hg for 10 seconds). A positive response was recorded if the manoeuvre provoked headache. All patients subsequently underwent brain MRI.
  
  
  RESULTS
  None of the patients had neurological signs. Eleven had positive modified Valsalva tests. Ten were found subsequently to have posterior fossa pathologies (secondary cough headache: 8 Chiari Type 1 malformations, 2 posterior fossa meningiomas). The cough headache was relieved following surgery in all cases. One patient with a positive Valsalva test had an apparently normal brain MRI but measurements of hindbrain and posterior fossa dimensions were consistent with 'posterior fossa crowdedness'. The remaining 5 patients had negative (4 patients) or equivocal (1 patient) Valsalva tests and normal MRI scans (primary cough headache).
  
  
  CONCLUSIONS
  These findings suggest that secondary cough headache results from a transient increase in intracranial CSF pressure during exertion in the presence of obstruction to normal cerebrospinal fluid dynamics. The modified Valsalva test can also determine whether tonsillar herniation found on brain MRI is symptomatic. Primary cough headache appears to be caused by a different mechanism, possibly through congestion of the orbital venous plexus in the presence of jugular venous incompetence and a reduced threshold for trigeminal sensory activation.
authors.affiliation: Charing Cross Hospital, Imperial College, London, UK. r.lane@imperial.ac.uk
authors.forename: Russell J M
authors.initials: RJ
authors.lastname: Lane
authors.forename: Paul T G
authors.initials: PT
authors.lastname: Davies
mesh_terms: D000328:Adult; D000368:Aged; D001921:Brain / Q000473:pathology*; D003371:Cough / Q000150:complications; D005260:Female; D051270:Headache Disorders, Primary / Q000175:diagnosis*; D051271:Headache Disorders, Secondary / Q000175:diagnosis*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D014636:Valsalva Maneuver; D055815:Young Adult
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