Headaches add to the burden of epilepsy

The objective was to investigate and classify headaches in 109 consecutive adult patients with epilepsy. A semi-structured interview was performed in those who confirmed such symptoms (65%). Interictal headaches were present in 52%; 20% had interictal migraine. Postictal headache was reported in 44%. Migraine characteristics were present in 42% of these, and most of them (74%) also suffered from interictal migraine. Six percent had preictal headache. In partial epilepsy, there was an association between headache lateralisation and interictal EEG abnormalities (p=0.02). We conclude that headache, including migraine, is very common in patients with epilepsy. Unilateral headache may represent a lateralising sign in focal epilepsy. Seizures often trigger postictal headaches with migraine features, which often are associated with interictal migraine. Migrainous headaches sometimes proceed into epileptic seizures. The comorbidity of migraine and epilepsy should receive ample clinical attention, as it may influence antiepileptic drug choice, and the headache may need specific treatment.     

Characteristics of postictal headache in patients with partial epilepsy

Migraine-like features sometimes characterize the headache that follows epileptic seizure (postictal headache, PIH). We compared patients with different types of epilepsy to investigate the association between migraine-like PIH and seizure type. Subjects comprised 364 patients with partial epilepsy. Epilepsy types were temporal lobe epilepsy (TLE, n = 177), frontal lobe epilepsy (FLE, n = 116), and occipital lobe epilepsy (OLE, n = 71). Patients participated in a structured interview pertaining to PIH as well as interictal headache and family history of migraine. Headaches were classified according to the International Headache Society criteria, which was modified for this study. Forty percent had PIH and 26% of these patients had migraine-like PIH. Migraine-like PIH occurred significantly more often in cases of TLE and OLE than in cases of FLE. In addition, the incidence of interictal migraine headache was significantly higher in patients with migraine-like PIH. These results suggest that migraine-like PIH is related to particular regions of epileptogenic focus and that susceptibility to migraine headache predisposes to migraine-like PIH.     

Characteristics of the first 1000 headaches in an outpatient headache clinic registry

(Headache 2011;51:226‐231) Objective.— To analyze the incidence and characteristics of the first 1000 headaches in an outpatient clinic. Background.— Headache is a common cause of medical consultation, both in primary care and in specialist neurology outpatient clinics. The International Classification of Headache Disorders, 2nd Edition (ICHD‐II), enables headaches to be classified in a precise and reproducible manner. Methods.— In January 2008, an outpatient headache clinic was set up in Hospital Clínico Universitario, a tertiary hospital in Valladolid, Spain. Headaches were classified prospectively in accordance with ICHD‐II criteria. In each case we recorded age and sex, duration of headache, ancillary tests required, and previous symptomatic or prophylactic therapies. Results.— In January 2010, the registry included 1000 headaches in 682 patients. The women/men ratio was 2.46/1 and the mean age of the patients was 43.19 ± 17.1 years (range: 14‐94 years). Patients were referred from primary care (53.4%), general neurology clinics (36.6%), and other specialist clinics (9%). The headaches were grouped (ICHD‐II classification) as follows: group 1 (Migraine), 51.4%; group 2 (Tension‐type headache), 16%; group 3 (Trigeminal autonomic cephalalgias), 2.6%; group 4 (Other primary headaches) and group 13 (Cranial neuralgias), 3.4%. The diagnostic criteria of chronic migraine were satisfied in 8.5% of migraines. Regarding secondary headaches, 1.1% of all cases were included in group 5 (Headaches attributed to trauma) and 8.3% in group 8 (Headaches attributed to a substance or its withdrawal). Only 3.4% of headaches were classified in group 14 (Unspecified or not elsewhere classified), and 5.2% were included in the groups listed in the ICHD‐II research appendix. Conclusion.— This registry outlines the characteristics of patients seen in an outpatient headache clinic in a tertiary hospital; our results are similar to those previously reported for this type of outpatient clinic. Migraine was the most common diagnosis. Most headaches can be classified using ICHD‐II criteria.     

High prevalence of headaches in patients with epilepsy

Background

To examine the association between headaches and epilepsy.

Methods

Consecutive adult epileptic patients who went to the outpatient clinic of the Epilepsy Center of PLA General Hospital between February 01, 2012, and May 10, 2013, were recruited into this study. A total of 1109 patients with epilepsy completed a questionnaire regarding headaches.

Results

Overall, 60.1% of the patients (male: 57.2%; female: 63.8%) reported headaches within the last year. The age-weighted prevalence of interictal migraine was 11.7% (male 8.9%, female 15.3%), which is higher than that reported in a large population-based study (8.5%, male 5.4%, female 11.6%) using the same screening questions. The prevalence of postictal headaches was 34.1% (males 32.7%, females 35.2%), and the presence of preictal headaches was 4.5% (males 4.3%, females 5.2%). The prevalence of headache yesterday in the general population was 4.8% (male 3.0%, female 6.6%). Thus, the prevalence of headaches, including migraine, is higher in epileptic patients in China.

Conclusions

The high prevalence of postictal headaches confirms the frequent triggering of a headache by a seizure. A much lower frequency of preictal headaches, a condition in which the real triggering effect of the headache on the seizure might be difficult to prove.     

Mild Head Trauma and Chronic Headaches in Returning US Soldiers

Objective.— To determine the incidence and types of head or neck trauma and headache characteristics among US Army soldiers evaluated for chronic headaches at a military neurology clinic following a combat tour in Iraq. Background.— Head or neck trauma and headaches are common in US soldiers deployed to Iraq. The temporal association between mild head trauma and headaches, as well as the clinical characteristics of headaches associated with mild head trauma, has not been systematically studied in US soldiers returning from Iraq. Methods.— A retrospective cohort study was conducted with 81 US Army soldiers from the same brigade who were evaluated at a single military neurology clinic for recurrent headaches after a 1‐year combat tour in Iraq. All subjects underwent a standardized interview and evaluation to determine the occurrence of head or neck trauma during deployment, mechanism and type of trauma, headache type, and headache characteristics. Results.— In total, 33 of 81 (41%) soldiers evaluated for headaches reported a history of head or neck trauma while deployed to Iraq. A total of 18 (22%) subjects had concussion without loss of consciousness and 15 (19%) had concussion with loss of consciousness. Ten subjects also had an accompanying traumatic neck injury. No subjects had moderate or severe traumatic brain injury. Exposure to blasts was the most common cause of trauma, accounting for 67% of head and neck injuries. Headaches began within one week after trauma in 12 of 33 (36%) soldiers with head or neck injury. Another 12 (36%) reported worsening of pre‐existing headaches after trauma. Headaches were classified as migraine type in 78% of soldiers with head or neck trauma. Headache types, frequency, severity, duration, and disability were similar for soldiers with and without a history of head or neck trauma. Conclusion.— A history of mild head trauma, usually caused by exposure to blasts, is found in almost half of returning US combat troops who receive specialized care for headaches. In many cases, head trauma was temporally associated with either the onset of headaches or the worsening of pre‐existing headaches, implicating trauma as a precipitating or exacerbating factor, respectively. Headaches in head trauma‐exposed soldiers are usually migraine type and are similar to nontraumatic headaches encountered at a military specialty clinic.     

Thunderclap Headache with Orgasm: A Case of Basilar Artery Dissection Associated with Sexual Intercourse

Background: Headaches associated with sexual intercourse (coital cephalgia) have many different causes and are often divided in the literature into pre-orgasmic and orgasmic headaches. Objective: To present a case of orgasmic headache caused by a basilar artery dissection and to present a literature-based guide to the diagnosis and management of patients presenting with headaches related to sexual activity. Case Report: We report the case of a 34-year-old man without significant past medical history who presented to the Emergency Department with two episodes of orgasmic headache caused by basilar artery dissection. Conclusions: The cause of headaches related to sexual activity range from the benign to the life-threatening. Due to the dynamics of cerebral blood flow during sexual intercourse, basilar artery dissections and aneurysms should be considered in patients with sudden-onset headaches during orgasm. Appropriate brain imaging and, possibly, lumbar puncture may assist in identifying potentially life-threatening causes of coital headaches.     

Headache in acute stroke. A prospective study in the first 8 days

We aimed to describe and classify headaches associated with acute stroke, by interviewing patients consecutively admitted to a stroke unit using a validated headache questionnaire and the International Classification of Headache Disorders of the International Headache Society (IHS). One hundred and twenty-four patients (61% ischaemic and 39% haemorrhagic stroke) reported headache. Headaches started mostly on the day of stroke, were more often continuous, pressure-type, bilateral and located in the anterior region, were increased by movement and by cough and lasted for a mean of 3.8 days. Tension-type was the most frequent type of headache. Eleven per cent of headaches could not be classified using the criteria of the IHS. Previous primary headache was documented in 71 patients. The presence of nausea/vomiting due to acute stroke can confound headache classification using the IHS criteria. In up to half of the patients, headache seems to be a reactivation of previous primary headache.     

Application of the ICHD-II criteria to the diagnosis of primary chronic headaches via a computerized structured record

BACKGROUND: The authors recently developed a software program designed to analyze clinical data from patients affected by primary headache. The program is based exclusively on the International Classification of Headache Disorders 2nd edition (ICHD-II) criteria. This software examines all the diagnoses of primary headaches on the basis of the variables needed to fulfill these mandatory criteria. METHODS: We tested the software, Primary Headaches Analyser 1.0 INT (PHA), by entering and analyzing clinical data from 200 consecutive patients affected by primary chronic headaches and evaluating the corresponding output diagnoses. RESULTS: The diagnosis of chronic migraine (1.5.1) was obtained in 68 cases (34 %) and that of probable chronic migraine (1.6.5) plus probable medication-overuse headache (8.2.8) in 46 (23%). Chronic tension-type headache (2.3) and probable chronic tension-type headache (2.4.3) plus probable medication-overuse headache (8.2.8) were diagnosed in 24 (12%) and 2 (1%) patients, respectively. Moreover, 4 and 12 patients, respectively, received both the diagnosis of chronic migraine (1.5.1) plus chronic tension-type headache (2.3) and of probable migraine (1.6.1) without aura plus chronic tension-type headache (2.3). In the remaining 44 cases (22%), none of the chronic primary headaches disorders defined by ICHD-II received an output diagnosis from the program. This was due mainly to the fact that the criteria fulfilled were insufficient for the diagnoses of migraine without (1.1) aura plus chronic migraine or, more infrequently, chronic tension-type headache. CONCLUSIONS: Our software program permitted diagnoses of chronic migraine, chronic tension-type or their probable forms (with or without MOH) in 78% of 200 patients with headache 15 or more days per month. In the remaining cases the inability to provide a specific diagnosis may be explained in part by the fact that the criteria for both diagnoses are too stringent and do not accurately reflect variations of the headache pattern in these chronic forms.     

The Prevalence of Headache in Greece: Correlations to Latitude and Climatological Factors

A questionnaire study on headaches, using a door-to-door survey, was carried out in a representative sample of the general Greek population, including 1737 men and 1764 women, from 15 to 75 years of age. The parameters evaluated included age, sex, education, socioeconomic status, region of domicile, frequency of headache, use of medication, medical consultation, and family history. Latitude and climatologic factors such as humidity, temperature, and atmospheric pressure were also investigated. Headaches were not classified because the interviewers were not specialists. Nineteen percent of men and 40% of women (mean 29%) suffered from headaches in the prior year. Headaches were more frequent in lower social classes, in people with less education, and in those between 45 and 64 years of age. Nineteen percent of sufferers did not take any medication and 33% used medication every time that they had a headache, while 36% sought medical consultation. Twenty-nine percent of headache sufferers had a family history of headaches. Daily headache was present in 15% of headache sufferers. Humidity and atmospheric pressure were not correlated to headache frequency. However, in the northern areas of Greece, as well as in the regions with low mean temperature, more people suffered from daily headaches. These data may explain the lower 1 -year prevalence of headaches in Greece as compared to the prevalence of headaches in other northern European countries.     

Intranasal lidocaine for migraine: a randomized trial and open-label follow-up

OBJECTIVE: To study the efficacy of intranasal lidocaine for the treatment of migraine when administered by subjects in a nonclinic setting. DESIGN: A 1-month, randomized, controlled, double-blind trial, followed by a 6-month open-label follow-up. SETTING: Ambulatory subjects treating themselves outside of a medical setting. SUBJECTS: One hundred thirty-one adult subjects with migraine, diagnosed according to International Headache Society criteria, were enrolled in the study: 113 treated at least one headache in the controlled trial, and 74 treated at least one headache in the open-label phase. All subjects were members of the Kaiser Permanente Southern California Medical Care Program and were recruited at two urban medical centers. INTERVENTION: Intranasal lidocaine 4% or saline placebo 0.5 mL was dropped into the nostril on the side of the headache, or bilaterally for bilateral headache, according to study protocol. MAIN OUTCOME MEASURES: Trial: percent of headaches relieved to mild or none at 15 minutes and relapse of headache within 24 hours. Open-label: percent of headaches relieved to mild or none at 15 and 30 minutes and relapse within 24 hours. RESULTS: In the controlled trial, headache was relieved within 15 minutes in 34 (35.8%) of 95 subjects treated with 4% intranasal lidocaine compared with 8 (7.4%) of 108 subjects receiving placebo (P < .001). Headaches relapsed in 7 (20.6%) of 34 subjects treated with 4% intranasal lidocaine compared to 0 of 8 placebo subjects (P = .312). In the open-label follow-up, headaches were relieved in 129 (41.2%) of 313 episodes within 15 minutes and in 141 (57.6%) of 245 episodes after 30 minutes. Headaches relapsed in 28 (19.9%) of 140. The response did not diminish over time: 32 (62.8%) of 51 first headaches were relieved at 30 minutes and 10 (71.4%) of 14 seventh headaches were relieved. Relapse occurred in 28 (20%) [corrected] of 129 headaches at a mean time (+/- SD) of 7.4 (+/- 6.6) hours. CONCLUSION: Intranasal lidocaine 4% provides rapid relief of migraine symptoms. For those subjects who do respond, the effect does not diminish over 6-month follow-up.     

Headaches in Insulin-Dependent Diabetic Patients

Headaches affecting 117 insulin-dependent diabetic patients were studied. 50 developed 3 varieties of headaches associated with clinical hypoglycaemic episodes: (1) Brief headaches, contemporaneous with cerebral and autonomic symptoms, were relieved within minutes of ingesting carbohydrates (8 patients). (2) Prolonged headaches outlasting hypoglycaemic symptoms by 1-48 (average 4.3) hours, not relieved by food, occurred in 36 patients; 12 of these also had nausea, vomiting or photophobia. (3) Migraine headache. 11 of the 117 patients were migraineurs: in 6 of the 11 their typical migraines (2 classical and 4 common) were induced by hypoglycaemic episodes. 9 of the 50 had 2 types of headaches, easily distinguished by each subject. In the whole series of 117 patients, 9 had never had a headache in their life. The remainder had headaches associated with premenstrual tension, anxiety, alcohol or other causes.     

幕上肿瘤伴发癫(癎)的精确定位和手术疗效分析

目的 探讨幕上肿瘤伴发癫(癎)的精确定位价值和手术治疗效果,研究肿瘤与致(癎)灶的关系.方法 对121例(胶质瘤Ⅰ级15例、Ⅱ级35例、Ⅲ～Ⅳ级12例,脑膜瘤32例,脑转移瘤10例,海绵状血管瘤15例,室管膜瘤2例)临床上以癫(癎)为首发症状的幕上肿瘤患者术前、术后癫(癎)发作情况等,临床资料进行回顾性分析.结果 采用术前影像和脑电结合定位、术中皮层脑电再次定位的方法,对肿瘤和癫(癎)灶同时切除,无手术死亡.癫(癎)发生率最高在额叶,最低在枕叶.癫(癎)灶与肿瘤的关系:位于同一部位者50例;致(癎)灶位于肿瘤一侧或近旁者28例;致(癎)灶位于肿瘤远隔部位(＞2 cm)25例;检测不到致痫灶者18例.失访18例,103例随访1～9年,31例术后早期仍有小发作,83例不再服抗癫(癎)药物癫(癎)症状完全消除.结论 在幕上肿瘤伴发癫(癎)患者中,致(癎)灶与肿瘤灶存在一定的差异性.在开颅切除肿瘤的同时必须明确致(癎)灶的位置和范围,一并切除才能达到良好的手术效果.     

Lateral temporal hyperperfusion in postictal psychosis assessed by 99mTc-HMPAO SPECT

Postictal psychosis is a rare complication of epileptic seizure characterized by reversible psychotic symptoms after flurries of seizure attack. It has been attributed to a phenomenon similar to Todd's paralysis without definitive proof. We studied regional cerebral blood flow (rCBF) of six patients with postictal psychosis by (99m)Tc-HMPAO SPECT scan. Baseline rCBF was compared with the rCBF during postictal psychosis. An asymmetry index (ASI) was calculated as 200 x [(ipsilateral ROI count density - contralateral ROI count density)/(ipsilateral ROI count density + contralateral ROI count density)] %. Significant differences could be found between ASIs during postictal psychosis and interictal state SPECT scan over the lateral temporal neocortex region (P = 0.017). Although hyperperfusion abnormality in SPECT can be found in Todd's paralysis, such findings are more commonly found in cerebral hyperactivity conditions. Taking into account the clinical characteristics of postictal psychosis, namely a preceding lucid interval and crescendo-decrescendo clinical course, these may be an alternative psychopathogenic mechanism for the development of postictal psychosis.     

Clinical symptoms in psychogenic seizures.

PURPOSE: To develop a classification system of psychogenic seizures based on characteristic clinical symptom clusters and sequences in order to facilitate the correct differential diagnosis of epileptic seizures. METHODS: We analysed the symptoms: clonic movements, hypermotor movements, trembling and tonic posturing of the upper/lower extremities, pelvic thrusting, stiffening of the body, version, side-to-side-head movements, non-versive head-turning and falling to the floor. We did this in a series of 16 patients with psychogenic seizures documented with prolonged video EEG monitoring. Nine patients (7 with frontal lobe epilepsy and 2 with primary generalised epilepsy with tonic, clonic seizures) served as a control group. RESULTS: We classified psychogenic seizures into 3 groups, namely (1) atonic psychogenic seizures, (2) psychogenic motor seizures and (3) psychogenic hypermotor seizures characterised by (1) falling to the ground, (2) trembling in the upper/lower extremities and (3) pelvic thrusting in combination with beating and kicking. While version exclusively occurred in epileptic seizures (incidence = 20%) and side-to-side head movements were only observed during psychogenic seizures (incidence = 8%), all other analysed symptoms were observed in both psychogenic and epileptic seizures. CONCLUSION: Our classification scheme should be useful in terms of permitting a more comprehensive clinical assessment of psychogenic seizures and their underlying psychiatric disorders. Furthermore, the differential diagnosis of psychogenic seizures should be considerably improved.     

Clinical Experience With Headaches in Preadolescent Children

We have reviewed the diagnoses of 654 children aged from 7 to 14 years who attended a neurologist for headache evaluation. Headaches beginning between the age of 7 and 14 represented a higher percentage (18.3%) than the proportion of preadolescent children in our health area (12.9%). Headaches were more common in girls; although cluster, posttraumatic, benign exertional headaches, and the only case of brainstem glioma were restricted to boys. Despite the female predominance, the proportion of males with migraine was significantly higher in the preadolescents than in the over 15 age group. Migraine accounted for the majority of diagnoses (609 - 93% of the total series), while tension-type headache (27 - 4%), and headache associated with sinus infection (7 - 1%) were the diagnoses which followed in frequency. There were only two headaches (0.3%) associated with intracranial masses.
Even though, in terms of frequency, headache is a very common reason for neurology consultation, the present results show that the majority of preadolescents consulting because of headache suffer from benign conditions.     

Relation Between Headaches and Neuropsychological Functioning Among Head Injury Patients

SYNOPSIS
The Luria-Nebraska Neuropsychological Battery (LNNB) and the Minnesota Multiphasic Personality Inventory (MMPI) were administered to 184 head injury patients with varying degrees of headache activity. A multiple regression analysis, controlling for neurological status, compared the 11 LNNB scores ofpatients with Daily Headache, Frequent Headaches, Infrequent Headaches, and No Headaches and foundthat the Arithmetic Scale was the only significant predictor, with the Daily Headache patients performing more poorly than the Infrequent Headache patients. A similar analysis of the 13 MMPI scores indicated that the K, He, and Pt Scales were significant predictors. However, post hoc Tukey tests revealed that K and Pt scores did not vary significantly among the four headache groups and only showed that Daily Headaches and Frequent Headaches patients had significantly higher Hs scores than the No headaches group. Subsequent comparisons of patients with and without headaches at the time of testing revealed no differences between the two groups on the LNNB and MMPI, after controlling for age, duration of symptoms, and neurological status. Overall, the results suggested that the relation between headache symptoms and neuropsychological functioning was insignificant.     

Headache and hemodialysis: a prospective study

OBJECTIVE: To determine the prevalence and clinical characteristics of headache in patients undergoing hemodialysis and to compare the prevalence of headache prior to and following the beginning of a hemodialysis program. BACKGROUND: About 70% of patients receiving hemodialysis complain of headache. Despite this, headaches have not been well studied in this group of patients. METHODS: We evaluated a series of patients with chronic renal failure who attended 3 hemodialysis services in a Brazilian town from January of 1998 to December of 1999. Patients with headache were prospectively followed and classified according to the International Headache Society criteria. The headaches were also categorized according to their temporal profile relative to hemodialysis. RESULTS: Headache was reported by 87 (70.7%) of the 123 patients studied. Prior to beginning dialysis, 48% had migraine, 19% had episodic tension-type headache, and 8% had both. Headache related to arterial hypertension was the second most frequent headache diagnosis in these patients (25.4%). Fifty patients (57.5%) experienced headache during the session of hemodialysis. Thirty-four were classified as dialysis headache, 7 were classified as migraine, 7 as episodic tension-type headache, and 2 were unclassified. Twenty-four patients (27.6%) reported dramatic improvement of their headaches after the beginning of the dialysis program. CONCLUSIONS: Headache is common in patients undergoing hemodialysis. Classification of such headaches according to the International Headache society criteria may be difficult.     

One or Several Types of Triptan Overuse Headaches?

Background.— Whereas the clinical features of pure triptan overuse headache (TOH) are well known, there are insufficient data regarding the semiological pattern of headaches when triptan overuse is associated with other types of medication overuse.
Objective.— To investigate and compare the clinical characteristics of patients with pure TOH and those with medication overuse headaches associating triptan and other medication overuses (combined TOH).
Methods.— This cross-sectional, observational study was conducted in 7 tertiary-care headache centers participating in the French Observatory of Migraine and Headaches. From 2004 to 2006, data from 163 patients with TOH were collected in face-to-face structured interviews (according to the International Classification of Headache Disorders, 2nd edition criteria).
Results.— Eighty-two patients fulfilled criteria for pure TOH (pTOH patients) and 81 for combined TOH (cTOH) patients. Continuous headaches were reported in 76% of cTOH patients compared with 32% of pTOH patients. Significantly more frequent and severe headaches and more intense phono-/photophobia between attacks were noted in cTOH patients. More cTOH than pTOH patients reported a history of tension-type headaches and a long-standing history of chronic headaches. Finally, compared with pTOH patients, cTOH patients were characterized by stronger dependence on acute treatments of headaches according to the DSM-IV criteria.
Conclusions.— Combined therapy with analgesics and/or the total number of drug units taken per day may cause a shift from a pattern of clear-cut headache attacks in patients with pTOH toward more severe clinical presentation in patients with cTOH. These patients should receive more intensive prophylactic therapy and specific behavioral management.     

Headaches precipitated by cough,prolonged exercise or sexual activity: a prospective etiological and clinical study

Headaches provoked by cough, prolonged physical exercise and sexual activity have not been studied prospectively, clinically and neuroradiologically. Our aim was to delimitate characteristics, etiology, response to treatment and neuroradiological diagnostic protocol of those patients who consult to a general Neurological Department because of provoked headache. Those patients who consulted due to provoked headaches between 1996 and 2006 were interviewed in depth and followed-up for at least 1 year. Neuroradiological protocol included cranio-cervical MRI for all patients with cough headache and dynamic cerebrospinal functional MRI in secondary cough headache cases. In patients with headache provoked by prolonged physical exercise or/and sexual activity cranial neuroimaging (CT and/or MRI) was performed and, in case of suspicion of subarachnoid bleeding, angioMRI and/or lumbar tap were carried out. A total of 6,412 patients consulted due to headache during the 10 years of the study. The number of patients who had consulted due to any of these headaches is 97 (1.5% of all headaches). Diagnostic distribution was as follows: 68 patients (70.1%) consulted due to cough headache, 11 (11.3%) due to exertional headache and 18 (18.6%) due to sexual headache. A total of 28 patients (41.2%) out of 68 were diagnosed of primary cough headache, while the remaining 40 (58.8%) had secondary cough headache, always due to structural lesions in the posterior fossa, which in most cases was a Chiari type I malformation. In seven patients, cough headache was precipitated by treatment with angiotensin-converting enzyme inhibitors. As compared to the primary variety, secondary cough headache began earlier (average 40 vs. 60 years old), was located posteriorly, lasted longer (5 years vs. 11 months), was associated with posterior fossa symptoms/signs and did not respond to indomethacin. All those patients showed difficulties in the cerebrospinal fluid circulation in the foramen magnum region in the dynamic MRI study and preoperative plateau waves, which disappeared after posterior fossa reconstruction. The mean age at onset for primary headaches provoked by physical exercise and sexual activity began at the same age (40 years old), shared clinical characteristics (bilateral, pulsating) and responded to beta-blockers. Contrary to cough headache, secondary cases are rare and the most frequent etiology was subarachnoid bleeding. In conclusion, these conditions account for a low proportion of headache consultations. These data show the total separation between cough headache versus headache due to physical exercise and sexual activity, confirm that these two latter headaches are clinical variants of the same entity and illustrate the clinical differences between the primary and secondary provoked headaches.