What is the workup for headaches that occur during Valsalva maneuver (bearing down) or defecation?

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 complete neurological examination, followed by brain imaging with MRI as the preferred modality to rule out serious conditions like Chiari malformation, intracranial masses, or vascular abnormalities. The workup for these headaches, known as exertional headaches or Valsalva-induced headaches, is crucial due to the potential for increased intracranial pressure during Valsalva maneuvers, which can stretch pain-sensitive structures 1.

Key Components of the Workup

• A detailed medical history focusing on headache characteristics, timing, and associated symptoms
• A complete neurological examination to identify any abnormalities
• Brain imaging with MRI to rule out serious conditions, as it is more sensitive than CT scan for detecting early changes of a stroke and other parenchymal abnormalities 1
• Additional testing may include MR angiography or venography to assess blood vessels, particularly if there is concern for venous sinus abnormalities or arterial dissection
• Possibly a lumbar puncture if increased intracranial pressure is suspected, to measure the pressure and analyze the cerebrospinal fluid

Symptomatic Management

• Indomethacin (25-50mg three times daily) is often effective for symptomatic management, with propranolol (40-160mg daily in divided doses) as an alternative 1
• These medications should be taken preventively before activities that trigger headaches to reduce the frequency and severity of the headaches

Lifestyle Modifications

• Patients should also be advised to avoid straining during bowel movements by increasing fiber intake, staying hydrated, and using stool softeners if needed to reduce the pressure on the brain during defecation

The most recent and highest quality study 1 emphasizes the importance of a thorough workup, including MRI, to exclude secondary causes of headaches that may require specific treatment, highlighting the need for a meticulous approach to diagnose and manage exertional headaches effectively.

From the Research

Headaches while Bearing Down/Defecating

• Headaches that occur while bearing down or defecating can be a symptom of various underlying conditions, and a thorough evaluation is necessary to determine the cause 2, 3, 4, 5.
• A careful history and physical examination are essential to identify secondary headache and to determine whether an immediate referral to the emergency department or a non-emergent referral to the neurologist is warranted 2, 3, 4.
• The majority of patients with primary headache may be safely managed in the outpatient setting, but patients with cluster headache, headache of uncertain diagnosis, or poor response to preventive strategies should be referred to a neurologist 4.
• Secondary headache and medication overuse headache should be considered in patients on long-term analgesics with unremitting headache 3, 4.
• A headache diary can document headache frequency, symptoms, initiating and exacerbating conditions, and treatment response over time, which can help identify patterns and potential triggers 3.
• Neurologic assessment and physical examination focused on the head and neck are indicated in all patients, and targeted imaging and other assessments may be necessary to exclude serious underlying conditions 3, 5.

Evaluation and Management

• A complete history is essential to identify the most likely headache type, indications of serious secondary headaches, and significant comorbidities 3.
• Patients presenting with headache should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder 5.
• Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine, while preventive treatments include antihypertensives, antiepileptics, antidepressants, and calcitonin gene-related peptide monoclonal antibodies 5.
• Constipation, which can be related to bearing down or defecating, can be treated with psyllium or sennosides, but docusate has not shown to be effective in older adults 6.

Workup

• A thorough workup for headaches while bearing down or defecating should include a careful history, physical examination, and neurologic assessment 2, 3, 4, 5.
• Targeted imaging and other assessments may be necessary to exclude serious underlying conditions, such as vascular, neoplastic, infectious, or intracranial pressure/volume causes 3, 5.
• A headache diary and screening tools such as SNNOOP10 can help identify patterns and potential triggers, and guide further evaluation and management 3.