Although headache is very common in society, not every headache is the same. Some types are considered alarm signs by their mode of onset and definitely require physician evaluation. Cough-related headache is one of them: it is a headache that starts during or immediately after a simple cough or other Valsalva maneuvers (straining, sneezing, blowing nose, laughing, heavy lifting, and other actions that increase intra-abdominal/thoracic pressure), with a clear trigger. In this article, we address the differences between the benign (primary) form and the form due to an underlying serious disease (secondary) of cough-triggered headache and diagnostic-treatment approaches.

What is Cough Related Headache?

According to the International Headache Society (IHS) definition, cough related headache is a type of headache where the pain is provoked only by coughing or other Valsalva maneuvers and occurs during or immediately after these actions; it does not start spontaneously. In the International Classification of Headache Disorders (ICHD-3), it is divided into two basic subtypes:

1. Primary cough headache: There is no brain formation or structural disorder underneath; the pain that occurs after coughing is the disease itself and is usually benign.
2. Secondary cough headache: The pain may be due to serious causes such as posterior fossa anomalies, brain masses/tumors, cerebrospinal fluid (CSF) pressure disorders between the skull and cervical vertebrae.

This distinction is of vital importance. Therefore, every patient experiencing cough triggered headache should be evaluated with detailed neurological examination and often imaging such as brain Magnetic Resonance (MRI). Early diagnosis both prevents unnecessary anxiety and enables rapid detection of underlying serious causes if present.

What Causes Cough Related Headache?

Cough triggered headache is divided into two basic groups: primary (primary) and secondary (secondary).
The causes and mechanisms of these two forms are completely different from each other.

1. Causes of Primary (Primary) Cough Headache

Primary cough headache is usually benign and there is no underlying structural brain disease.
Although the exact mechanism is not fully known, the strongest theory relates to sudden increase in intracranial pressure during coughing or straining.

This sudden pressure increase creates brief stretching in pain sensitive structures in the brain (vessels, meninges, and venous sinuses).
This stretching triggers pain especially in individuals more sensitive to pressure.

In some patients, mechanisms that balance intracranial pressure cannot respond quickly enough; this is felt as brief, sharp pains after Valsalva maneuver.
In short, in primary cough headache, there is no structural damage, only physiological pressure increase provokes pain.

2. Causes of Secondary (Secondary) Cough Headache

Secondary cough headache occurs when there is serious brain or spinal cord pathology underneath. In this form, pain should be considered as a warning signal.

The most common causes are:

• Chiari Malformation (Type I):
  It is the most common cause of secondary cough headache.
  The lower parts of the cerebellum hang down more than normal, toward the beginning of the spinal canal.
  The increased pressure during coughing or straining temporarily blocks the flow of cerebrospinal fluid (CSF), causing sudden pressure increase inside the skull and severe, explosive-type headache develops.
• Brain Tumors (especially posterior fossa tumors):
  Tumors in the posterior fossa of the brain can cause pain with coughing by blocking CSF flow or compressing the brainstem.
• Brain Aneurysms (Vascular Balloons):
  Unruptured aneurysms can cause temporary pain with increased intracranial pressure.
  They should definitely be ruled out especially in pains described as “sudden, lightning like.”
• Intracranial Pressure Disorders:
  • Spontaneous intracranial hypotension: Occurs as a result of decreased CSF pressure due to a small leak in the meninges.
  • Idiopathic intracranial hypertension: A condition where CSF pressure is high.
    In both cases, coughing triggers pain by increasing pressure changes.
• Other Causes:
  Meningitis, encephalitis, subdural hematoma (bleeding under the meninges), or conditions developing after head trauma can also provoke pain with coughing.

Conclusion:
The cause of cough related headache can range from simple pressure changes to serious brain structural disorders.
Therefore, in every individual experiencing this type of headache, detailed neurological examination and often brain MRI imaging evaluation is recommended.
This examination performed early is of critical importance for ruling out secondary causes and directing treatment correctly.

Who Gets Cough Related Headache?

Although cough related headache can be seen at any age, primary (benign) and secondary (due to underlying disease) forms tend to occur in different age groups.

1. Primary (Primary) Cough Headache

• Usually seen in individuals over 40 years of age.
• Reported more frequently in men compared to women.
• In this group, pain is triggered by actions such as coughing or straining, but there is no structural abnormality in the brain.
• It is often benign and can be controlled with appropriate treatment.

2. Secondary (Secondary) Cough Headache

• Can be seen at any age, but should be carefully evaluated especially in individuals under 40 years of age.
• In cough triggered headaches occurring in this age group, the possibility of an underlying structural cause (e.g., Chiari Type 1 malformation) is higher.
• Therefore, if such pains exist in a young patient, detailed examination with brain MRI is recommended.

Conclusion:
The age at which cough related headache begins is an important diagnostic clue.

• If middle aged or older, the primary form is more likely.
• If it occurs at a young age, secondary causes (such as Chiari malformation) must definitely be ruled out.

What Are the Symptoms of Cough Related Headache?

Cough triggered headache can be seen in both primary (benign) and secondary (due to underlying disease) forms.
The difference between the symptoms of these two forms is extremely important for diagnosis.

1. Primary Cough Headache Symptoms

• Sudden onset: Pain suddenly starts with or immediately after coughing, sneezing, or straining.
• Short duration: Typically lasts between 1 second and 30 minutes and then completely disappears.
• Pain character: Described as sharp, stabbing, “explosive” type, or as if pressure is being applied from inside the head outward.
• Location: Usually bilateral, sometimes can be felt localized at the back of the head or on one side.
• Absence of accompanying symptoms: There are no neurological symptoms such as nausea, visual disturbance, loss of balance, or weakness.
• Benign course: Generally responds well to treatment and does not indicate a serious disease.

2. Secondary Cough Headache Symptoms

The secondary form usually occurs due to causes such as Chiari malformation, tumor, aneurysm, or intracranial pressure disorders.
Symptoms generally last longer and are accompanied by additional findings that are “red flag” in nature.

• Longer lasting pain: Headache can last for hours or even days.
• Location: Mostly in the back of the head (occipital region)
• Accompanying neurological findings:
  • Dizziness or imbalance
  • Blurred vision or double vision
  • Hearing loss, tinnitus
  • Difficulty swallowing or voice change
  • Clouded consciousness or fainting
  • Weakness, numbness in arms or legs
    If any of these findings exist, brain MRI must definitely be done to rule out secondary causes.

International Classification of Headache Disorders (ICHD 3) Diagnostic Criteria  4.1 Primary Cough Headache

A. Presence of headache attacks triggered by coughing, straining, sneezing, laughing, or other Valsalva maneuvers
B. Headache having sudden onset and lasting between 1 second and 2 hours
C. Headache occurring in at least 2 separate attacks
D. Absence of a structural intracranial disorder that could cause headache (e.g., Chiari malformation, tumor, etc.)
E. Cannot be explained by another headache syndrome

Typical Features

• Usually felt bilaterally or in the occipital region
• Pain is sharp, stabbing, explosive, or splitting in nature
• Attacks are very brief, but can be recurrent
• Generally responds well to indomethacin treatment

How is Cough Related Headache Diagnosed?

The main purpose of diagnosis is to distinguish primary and secondary forms from each other.
Because the treatment approach depends entirely on this distinction.

1. Detailed History and Neurological Examination

The neurology specialist inquires about when, how, and under what conditions the pain started, how long it lasted, and whether it is related to other symptoms.
Balance, reflexes, muscle strength, and eye movements are carefully evaluated in physical examination.

2. Brain Imaging

Imaging is mandatory in this type of headache.

• Magnetic Resonance Imaging (MRI):
  It is the gold standard in diagnosis.
  It shows the brainstem, posterior fossa, and spinal junction region in high detail.
  It is the most reliable method especially for detecting structural causes such as Chiari malformation or tumor.
• Computed Tomography (CT):
  Can be used in emergency situations or when bleeding is suspected; however, it is not as sensitive as MRI in showing posterior fossa pathologies.

If imaging is completely normal and there are no neurological examination findings, the diagnosis is made as “Primary Cough Headache”.
In this case, the patient is generally followed up with medical treatment and measures to reduce pressure changes.

Conclusion:
Cough related headache, although often benign, can rarely be an early warning of serious neurological diseases.
Therefore, in recurrent or prolonged headaches starting with coughing, brain MRI should definitely be done and evaluated by a neurology specialist.

Treatment of Cough Related Headache

The treatment approach for cough triggered headache varies according to whether the diagnosis is primary (benign) or secondary (due to underlying disease).
The goal is both to identify the cause of pain and to control symptoms.

1. Primary (Primary) Cough Headache Treatment

This form is generally benign and the treatment plan is arranged according to the frequency, severity, and effect on the patient’s quality of life of the pain.

Drug Treatment

• Indomethacin is considered the first line and most effective drug in primary cough headache.
  • Its mechanism of action is to balance intracranial pressure by reducing prostaglandin synthesis in brain vessels.
  • Dramatic response is obtained in most patients; pains can completely disappear.
  • However, it should be used carefully in people with stomach problems, reflux, or kidney problems.
• Alternative drugs:
  The following agents can be tried in cases where indomethacin cannot be tolerated:
  • Acetazolamide: Reduces cerebrospinal fluid (CSF) production, lowers intracranial pressure.
  • Propranolol: Can be preferred especially in the presence of accompanying hypertension, migraine, or tremor.
  • Neuromodulator drugs such as topiramate or gabapentin may be beneficial in resistant cases.

Control of Triggering Factors

Treatment of conditions causing cough such as bronchitis, COPD, allergy, or sinusitis also ensures a reduction in pain attacks.
Thus, not only the result of the symptom but also the triggering cause is eliminated.

2. Secondary (Secondary) Cough Headache Treatment

In this form, the main goal is treatment of the underlying disease causing headache.

Chiari Malformation

• In symptomatic Chiari Type 1 cases, surgical decompression surgery is performed.
  This procedure eliminates the compression in the posterior fossa of the skull and normalizes CSF flow.
  After surgery, pain complaints significantly decrease in most patients.

Brain Tumors and Other Lesions

• Treatment varies according to the tumor’s location, type, and size.
  Combinations of surgery, radiotherapy, and/or chemotherapy can be applied.
• In cases such as aneurysm, bleeding, or pressure disorder, neurosurgery and neurology teams work together.

3. Lifestyle and Supportive Approaches

• Avoiding heavy lifting, straining, and prolonged coughing can reduce attacks.
• Regular breathing exercises and posture correcting physical therapy programs alleviate cough triggers by maintaining intrathoracic pressure balance.
• Drinking plenty of water, adequate sleep, and stress management also support overall neurological balance.

Conclusion:
Although cough related headache often has a benign course, it can rarely be the first sign of serious neurological diseases.
Therefore, sudden and severe headaches starting with coughing, sneezing, or straining should definitely be evaluated by a neurology specialist.
With early diagnosis and appropriate treatment, both the cause of pain can be determined and quality of life can be rapidly improved.

Frequently Asked Questions About Cough Related Headache

1. I feel pressure in my head every time I cough. Is this Cough Related Headache?

Due to the brief increase in intracranial pressure with every cough, a slight fullness or pressure sensation can occur — this is physiological and a normal condition.
However, if there is suddenly onset, sharp, stabbing, explosive type, and disturbing pain with coughing, this may be Cough Related Headache.
It should not be confused with simple pressure sensation. If the pain is pronounced or has become recurrent, it should be evaluated by a neurology specialist.

2. Does headache starting with coughing always indicate a serious condition such as brain tumor or Chiari malformation?

No, not always.
The Primary (Primary) form of this headache is quite common and is generally benign.
However, in some cases, pain may be a sign of a structural problem such as Chiari malformation, brain tumor, or pressure disorder (Secondary form).
Individuals experiencing cough triggered headache for the first time should definitely be examined with brain MRI imaging to rule out these serious causes.

3. What are the warning (alarm) signs that suggest my headache is from a dangerous cause?

If the following symptoms exist, the headache may be an indicator of an underlying serious problem and a doctor should be consulted without delay:

• Dizziness or imbalance
• Blurred or double vision
• Fainting, clouded consciousness
• Pain lasting longer than 30 minutes
• Numbness, weakness in arms or legs
• Impairment in vision, hearing, or swallowing functions

Additionally, seeing such pains in individuals under 40 years of age increases the possibility of Chiari malformation and definitely requires detailed investigation.

4. My head hurts when I cough, what should I do and which doctor should I go to?

The specialty to be consulted for such a complaint is Neurology.
After listening to your history, the neurology specialist clarifies the diagnosis by requesting brain MRI.
Through this imaging, structural causes such as Chiari malformation, tumor, or pressure disorders are ruled out.
If MRI results are normal and typical features exist, a diagnosis of “Primary Cough Headache” is made. In this case, treatment can be done quite successfully with medications.

5. The tests came out clean, I was diagnosed with “Primary Cough Headache”. Do I have to live with this pain?

Absolutely not.
Primary cough headache is benign and responds very well to treatment.
The most effective drug is Indomethacin; it completely or largely eliminates pain in most patients.
If the drug is not suitable, your doctor can plan alternative treatment options (acetazolamide, propranolol, CSF pressure lowering treatments).
Response to treatment usually begins within a few days and quality of life rapidly improves.

6. Is drug treatment really effective in cough related headache?

Yes. Scientific studies show that especially Indomethacin treatment provides significant improvement in 70-90% of primary cough headache patients.
If the drug cannot be tolerated, successful results can also be obtained with drugs such as propranolol, acetazolamide, or topiramate.
However, before starting treatment, it must be ensured that underlying secondary causes have been ruled out.