This is a sudden onset headache, triggered by coughing or straining (Valsalva) activities such as having a bowel movement, laughing, sneezing, blowing the nose, bending forward, holding the breath, singing, or lifting something heavy to give some examples. The headache is sudden onset and reaches its peak level of pain almost immediately. It usually lessens over seconds to minutes, although a mild to moderate headache can persist up to 1-2 hours. The location of the pain is often both sides of the head and in the back of the head, but this can vary.
It is most often a benign headache syndrome, but can also be associated with Chiari malformation, spinal fluid leak, vascular disorders, brain tumors, other structural abnormalities, aneurysm, tearing of an artery (dissection), other vascular abnormalities, or other “secondary causes”. Therefore, an evaluation with brain scans (brain MRI and brain and carotid artery MRA, or brain and carotid CTA) to exclude these potential treatable causes is necessary. It cannot be diagnosed until examination, further history, a recurrent pattern, and evaluations to exclude other causes of the headache have been performed with a physician. This headache requires urgent evaluation at the nearest emergency department for testing and evaluation, especially the first time that it occurs. One of the main diagnoses that needs to be evaluated for is a blood vessel related headache such as subarachnoid hemorrhage from aneurysm rupture (brain bleed).