We have discussed several miscellaneous
headache disorders not associated with structural
brain disease. The first group included those
headaches provoked by "exertional" triggers in various forms. These include
benign cough headache, BEH, and
headache associated with sexual activity. The IHS diagnostic criteria were discussed.
Benign exertional headache and
cough headache were discussed together because of their substantial similarities. In general, BEH is characterized by severe, short-lived
pain after coughing,
sneezing, lifting a burden, sexual activity, or other similar brief effort. Structural disease of the brain or skull was the most important differential diagnosis for these disorders, with posterior fossa mass lesions being identified as the most common organic etiology. Magnetic resonance imaging with special attention to the posterior fossa and foramen magnum is the preferred method for evaluating these patients.
Indomethacin is the treatment of choice. The
headache associated with sexual activity is dull in the early phases of sexual excitement and becomes intense at orgasm. This
headache is unpredictable in occurrence. Like BEH, the
headache associated with sexual activity can be a manifestation of structural disease.
Subarachnoid hemorrhage must be excluded, by CT scanning and CSF examination, in patients with the sexual
headache. Benign
headache associated with sexual activity has been successfully treated with
indomethacin and beta-blockers. The second miscellaneous group of
headache disorders includes those provoked by eating something cold or
food additives, and by environmental stimuli. Idiopathic
stabbing headache does not have a known trigger and appears frequently in migraineurs. Its occurrence may also herald the termination of an attack of
cluster headache.
Indomethacin treatment provides significant relief. Three
headaches triggered by substances that are eaten were reviewed: ingestion of a cold stimulus,
nitrate/
nitrite-induced
headache, and
MSG-induced
headache. For the most part, avoidance of these stimuli can prevent the associated
headache. Lastly, we reviewed
headache provoked by high altitude and
hypoxia. The
headache is part of the syndrome of AMS during its early or benign stage and the later malignant stage of HACE. The
pain can be exacerbated by exercise. The best treatment is prevention via slow ascent and avoidance of respiratory depressants.
Acetazolamide and
dexamethasone have proved useful in preventing this syndrome.