5.18.16 – VA Ambulatory Report Pearls – Laugh Headache + Chiari Malformation

Laugh Headaches

  • The symptom of a very short-lived headache (lasting seconds) exacerbated or triggered by laughing and coughing has been identified in case reports in the literature as being associated with Chiari type I malformations.
  • Mechanisms
    • The mechanism behind short-lived headaches in Arnold-Chiari type I malformations is thought to be due to the downward displacement of the cerebellar tonsils –> stretching of pain-innervated structures (meninges, nerve roots, and vasculature)
    • Laughter/cough/valsalva –> increase in intrathoracic pressure -> increase in intrathecal pressure –> obstruction of CSF flow –> stretching of pain-inntervated structures (see above)
  • Can be associated with Chiari malformations of which there are various types. Chiari type I malformation is defined as a 5mm displacement of the cerebellar tonsils through the foramen magnum
  • Treatment
    • Varies depending on the type of Chiari malformation. Chiari type II and III are typically managed surgically. Type I malformations depend on symptoms and if syringomyelia is present.
    • Asymptomatic patients with Chiari type I malformation (and without syringomelia) are managed conservatively with clinical symptom and MRI surveillance.
    • Symptomatic patients with Chiari type I malformation (especially if impacting quality of life) and lower CN palsies, syringomyelia, myelopathy, cerebellar symptoms, or severe neck pain/occipital headache often go on to surgical decompression. As mentioned in report, symptoms are relieved in ~2/3 of patients whereas 1/3 of patients have stable (preoperative) symptoms and ~10% go on to need repeat surgeries.

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