Pathophysiology of headache associated with cough in patients with Chiari I malformation

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Object. 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.

Article Information

Address reprint requests to: John D. Heiss, M.D., Surgical Neurology Branch, National Institutes of Health, 10 Center Drive, 10–5D37, MSC-1414, Bethesda, Maryland 20892–1414. email: heissj@ninds.nih.gov.

© AANS, except where prohibited by US copyright law.

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Figures

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    Scatterplot of peak intrathecal pressure during a cough in patients with or without headache associated with cough and in healthy volunteers. Bars indicate mean values.

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    Scatterplot of peak intrathecal pressure during a cough in patients with Chiari I malformation (with or without syringomyelia) and in healthy volunteers.

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    Graphs of intrathecal pressure compared with time during several coughs before and after surgery in a patient with headache associated with coughing.

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    Scatterplot showing intrathecal pressure during coughing before and after patients underwent surgery.

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