From the Guidelines
Headaches that occur during bearing down or defecation should be evaluated with a thorough neurological workup, starting with a detailed medical history and physical examination, followed by brain imaging with MRI as the preferred modality due to its superior ability to detect posterior fossa abnormalities, Chiari malformations, and vascular issues 1. The workup should focus on identifying potential underlying causes of the headaches, such as increased intracranial pressure, vascular abnormalities, or structural lesions.
- A complete neurological assessment should be performed, with special attention to signs of increased intracranial pressure, such as papilledema, visual field defects, or cranial nerve palsies.
- Brain imaging with MRI is essential, as it can detect posterior fossa abnormalities, Chiari malformations, and vascular issues that can cause these symptoms 1.
- Additional testing may include MR angiography or venography to evaluate vascular structures, particularly if there is suspicion of vascular abnormalities or venous sinus thrombosis 1.
- Lumbar puncture might be necessary if imaging is normal but suspicion remains high for conditions like spontaneous intracranial hypotension or idiopathic intracranial hypertension. While awaiting diagnosis, patients can be advised to avoid straining during bowel movements by:
- Increasing fiber intake (25-30g daily)
- Staying well-hydrated
- Possibly using stool softeners like docusate sodium (100mg twice daily) Indomethacin (25-50mg three times daily) may help manage symptoms temporarily, as it has been shown to be effective in treating exertional headaches 1. These headaches occur because bearing down increases intrathoracic pressure, reducing venous return and transiently raising intracranial pressure, which can reveal underlying abnormalities or trigger pain in susceptible individuals.
From the Research
Headaches while Bearing Down/Defecating
- The exact cause of headaches while bearing down or defecating is not explicitly stated in the provided studies, but it can be related to various factors such as constipation or straining during bowel movements.
- According to 2, headaches can be diagnosed by a careful history and physical examination, and imaging is generally not warranted.
- In terms of treatment, 2 suggests that early initiation of therapy and adequate dosing at first dose are important, and careful attention to avoiding too frequent administration of acute therapy is necessary to avoid medication overuse headaches.
Constipation and Defecation
- Studies 3 and 4 discuss the effectiveness of docusate for constipation, particularly in older people, and found that it does not show any benefits compared to placebo or other treatments like psyllium or sennosides.
- 3 and 4 suggest that docusate is commonly used for constipation despite little evidence supporting its efficacy, and healthcare providers should reassess its use.
- However, these studies do not directly address the relationship between constipation, defecation, and headaches.
Other Possible Factors
- Study 5 is unrelated to the topic of headaches while bearing down or defecating, as it discusses the relationship of infantile vesicoureteric reflux to renal damage.
- There is no direct evidence in the provided studies to support a specific workup for headaches while bearing down or defecating, but a careful history and physical examination, as suggested by 2, may be a good starting point.