Modified Valsalva test differentiates primary from secondary cough headache

Table 1 Response to modified Valsalva test and brain MRI results in 16 patients with ‘cough headache’

No	Age	Sex	Location	Triggers	Immediate preceding history	Headache history	Valsalva test response	MRI brain
1	22	F	Holocranial	Coughing, lifting, standing from lying	None	None. MO subsequently	+	Chiari 1
2	28	M	R Frontal	Coughing, laughing, sexual intercourse, bening over	URTI	None	±	Normal
3	57	F	Holoccanial	Coughing, sneezing, bending over, crouching	URTI	Facial migraine, tension headache, auras	-	Normal
4	30	F	Holocranial, R parietal	Standing up from a crouch	None	MO, exertional headache	+	Chiari 1
5	32	F	Occipital	Coughing, laughing, sneezing, bending over	None	MO	+	Chiari 1
6	65	M	Occipital	Coughing, bending over, stooping, lifting, straining at stool	None	Laughing headache	+	Chiari 1
7	63	M	L Frontal	Coughing, bending over	URTI	MO	-	Normal
8	87	M	Frontal	Coughing, sneezing	None	None	-	Normal
9	63	F	Vertex	Coughing, straining, laughing, bending over	None	MO	+	Posterior fossa meningioma
10	30	F	Occipitonuchal	Coughing	None	MO, thunderclap	+	Chiari 1
11	36	M	Frontal	Laughing, bending over, coughing	None	None	+	Chiari 1
12	43	F	Vertex	Coughing, sneezing, lifting	None	MO, MO with trigeminal autonomic symptoms	+	Chiari I
13	38	M	L fronto-temporal	Golf swing, bending over, lifting	None	MA	-	Normal
14	62	F	R frontal, any area	Coughing, bending over, sneezing, straining at stool	Cervical manipulation	None	+	‘Posterior fossa crowdedness’ ¹
15	46	F	Occipital	Coughing, shouting, sneezing, bending over, turning quickly	None	None	+	Posterior fossa meningioma
16	32	F	Holocranial, frontal	Bending over, lifting, blowing up balloons	None	MO, exercise-triggered migraine	+	Chiari 1

10 patients had positive tests and abnormal MRI (8 Chiari 1 malformation, 2 posterior fossa meningiomas. Patient 14 had a positive test with normal MRI but had a high hindbrain to posterior cranial fossa ratio consistent with ‘posterior fossa crowdedness’ [14]. 4 patients had negative tests and one an equivocal response (primary cough headache, PCH). Patients 4, 13 and 16 had ‘cough headache’ but did not complain of headache with coughing.

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