Cough Headaches: Should Evaluation Stop at Brain MRI?

Headaches triggered by coughing or other Valsalva maneuvers, such as sneezing, laughing, or blowing the nose, may indicate a range of underlying disorders. Speaking at the French Language Neurology Days (JNLF) 2026, Caroline Roos, MD, a neurologist at Hôpital Lariboisière, part of the Assistance Publique–Hôpitaux de Paris, in Paris, reviewed the differential diagnosis of cough-induced headache, emphasizing that advances in MRI have broadened the range of identifiable causes.If headaches persist despite a normal brain MRI, "spinal imaging should be performed to look for a dural tear or a veno-dural fistula" so that appropriate treatment can be offered, Roos said. Disorders of cerebrospinal fluid (CSF)circulation are among the potential causes of cough-induced headaches.Coughing and other Valsalva maneuvers produce a sudden increase in intracranial pressure, which can trigger headaches. "Abdominal and thoracic pressure increase, venous return decreases, leading to dilation of the epidural veins and a rise in intracranial pressure," said Roos.Look for Chiari MalformationAccording to several studies, secondary cough-induced headache generally affects young patients (mean age, 44 years), most often women. The pain is usually localized to the occipital or suboccipital region, may be "explosive," and typically correlates with the intensity of the cough.Although the pathophysiology of cough-induced headaches has not been fully established, several disorders have been implicated. The most common condition is a narrow posterior cranial fossa, associated with Chiari malformation. Downward displacement of the cerebellar tonsils compresses the brainstem and disrupts CSF circulation.In a Spanish study of nearly 6500 patients evaluated at a specialized headache center over 10 years, fewer than 1% had headaches triggered by coughing. Among these patients, 60% had secondary headaches. Chiari malformation was identified in 80% of the cases, and MRI demonstrated impaired CSF flow at the foramen magnum."When evaluating a headache triggered by coughing, it is essential to perform a comprehensive imaging workup," said Roos.Similarly, another study reported that approximately 1% of patients presenting with headaches had cough-induced headaches. Secondary causes include Chiari malformation, sphenoid sinusitis, brain metastases, subdural hematoma, and meningioma.Comprehensive Imaging EvaluationRoos outlined the conditions that should be considered in the differential diagnosis of cough-induced headaches as follows:"When evaluating a headache triggered by coughing, it is essential to perform a comprehensive imaging workup," Roos emphasized.Gadolinium-enhanced brain MRI is recommended to evaluate the meninges in patients with suspected spontaneous intracranial hypotension, assess the intracranial arteries and veins, and identify cerebellar tonsillar herniation associated with Chiari malformation.If brain MRI findings are normal but the primary cough headache remains refractory to treatment, Roos recommends spinal imaging to evaluate for a dural tear, a defect in the dura mater that results in CSF leakage, or a veno-dural fistula, a vascular malformation involving the dura mater.Primary cough headache is defined as "a headache triggered solely by coughing or another Valsalva maneuver, not by prolonged physical exertion, and not attributable to another intracranial disorder."According to the latest diagnostic criteria, patients must experience at least two episodes of headache triggered by coughing or another Valsalva maneuver, lasting from 1 second to 2 hours. The onset must be sudden, and the headache must not be better explained by another diagnosis.Indomethacin Remains Standard TreatmentPrevious diagnostic criteria limited headache duration to no more than 30 minutes, Roos noted. "Beyond that, we should consider a secondary cause."Primary cough headache typically affects older adults (mean age, 60 years) and is more common in men, accounting for 75%-85% of cases. The headache is usually bilateral, localized to the frontal region, lasts less than 1 minute , occurs episodically, and is not accompanied by symptoms such as nausea.Management begins with the evaluation and treatment of the underlying cough and any contributing factors. The standard pharmacologic treatment is the nonsteroidal anti-inflammatory drug indomethacin at a dose of 25-150 mg/d for approximately 5 months. The dose may be increased to 250 mg/day when clinically indicated."Recent studies have identified underlying disorders after an initial diagnosis of primary cough headache, including transverse venous sinus stenosis, dural tears, and veno-dural fistulas," Roos said. "These findings highlight the need for further evaluation, including lumbar puncture with measurement of opening pressure, spinal MRI, and myelography."She concluded, "We certainly need to conduct much more extensive investigations before diagnosing primary cough headache."This story was translated from Medscape's French edition.