Activity-related
headaches can be brought on by Valsalva maneuvers ("
cough headache"), prolonged exercise ("exertional
headache"), and sexual excitation ("orgasmic
headache"). These
headaches account for 1-2% of the consultations due to
headache in a general neurological department. These entities are a challenging diagnostic problem as they can be primary or secondary and as their etiologies differ depending on the
headache type. About 50% of patients with
cough headache will show no demonstrable etiology, while the other half will be secondary to structural lesions, mostly a Chiari type I malformation at the foramen magnum level. As compared to the primary variety, secondary
cough headache begins earlier (average 40 versus 60 years), is located posteriorly, lasts longer (years versus months), is associated with posterior fossa symptoms/signs, and does not respond to
indomethacin. Patients with secondary
cough headache show difficulties in cerebrospinal fluid circulation in the foramen magnum region in dynamic magnetic resonance imaging studies and preoperative plateau waves, which disappear after posterior fossa reconstruction.
Headaches provoked by physical exercise and sexual
headache have many points in common. In contrast to
cough headache, secondary cases are rare, and sentinel subarachnoid
bleeding is the most frequent etiology. The mean age at onset for primary
headaches provoked by physical exercise and sexual activity is similar (40 years); they share clinical characteristics (bilateral, pulsating) and respond to beta-blockers. In conclusion, provoked
headaches account for a low proportion of
headache consultations.
Cough headache is a different condition when compared to
headache due to physical exercise and sexual activity, which are clinical variants of the same entity.