4.1 Primary cough headache

Previously used terms:

Benign cough headache; Valsalva-manœuvre headache.


Headache precipitated by coughing or other Valsalva (straining) manœuvre, but not by prolonged physical exercise, in the absence of any intracranial disorder.

Diagnostic criteria:
  1. At least two headache episodes fulfilling criteria B-D
  2. Brought on by and occurring only in association with coughing, straining and/or other Valsalva manœuvre1
  3. Sudden onset2
  4. Lasting between 1 second and 2 hours2
  5. Not better accounted for by another ICHD-3 diagnosis3.
  1. Headache arises moments after the cough or other stimulus
  2. Headache reaches its peak almost immediately, and then subsides over several seconds to a few minutes (although some patients experience mild to moderate headache for two hours).
  3. The syndrome of cough headache is symptomatic in about 40% of cases, and the majority of patients in whom this is so have Arnold-Chiari malformation type I. Other reported causes include spontaneous intracranial hypotension, carotid or vertebrobasilar diseases, middle cranial fossa or posterior fossa tumours, midbrain cyst, basilar impression, platybasia, subdural haematoma, cerebral aneurysms and reversible cerebral vasoconstriction syndrome. Diagnostic neuroimaging plays an important role in the search for possible intracranial lesions or abnormalities. Since subtentorial tumours accounted for more than 50% of intracranial space-occupying lesions in children, cough headache in paediatric patients should be considered symptomatic until proved otherwise.

4.1 Primary cough headache is a rare condition, accounting for 1% or fewer of all headache patients consulting neurological clinics. However, one report found one fifth of patients with cough seen in a chest medicine clinic had cough headache.

4.1 Primary cough headache is usually bilateral and posterior, and predominantly affects patients older than 40 years of age. There is a significant correlation between the frequency of cough and the severity of the headache. Associated symptoms such as vertigo, nausea and sleep abnormality have been reported by up to two-thirds of patients with 4.1 Primary cough headache.

While indomethacin (50-200 mg/day) is usually effective in treating 4.1 Primary cough headache, a few symptomatic cases have been reported to respond to this treatment.