New Type of Chronic Daily Headache in Older Women?

RESEARCH UPDATE

Women often experience perimenopausal changes in headache frequency, when migraines may worsen or new types of headaches begin. The following case series describes a possible new type of chronic daily headache that appears to develop in overweight/obese women around the time of menopause or after.¹

History

The case series concerns eight women who were seen by a single neurologist at the Mayo Clinic, Jacksonville, FL over the course of one year. All the women described recent onset (within the last year) bilateral daily head pain. Pain was worse in the morning just before rising from bed, with reported intensity ranging up to 10/10. Only one out of the eight women described co-occurring migraine features. None were able to identify triggers.

The average age of onset was 57 years (two women were perimenopausal, the remainder were menopausal). Six out of the eight had a history of episodic migraine, which was either well controlled or in remission when the new headache symptoms started. Six out of the eight were either overweight or obese.

Diagnostic tests

All patients had normal ophthalmic exams, with no evidence of disc edema. Trendelenburg in the 10 degree head-down tilt position precipitated immediate worsening of symptoms in all patients. MRI with or without contrast and MR venography were normal, except for small incidental venous anomalies in three patients. Lumbar puncture (LP) was performed on two patients and showed normal to low opening pressure. Both developed post-LP headaches.

Treatment

LP was not deemed curative. All women showed rapid response (within 2 to7 days) with near complete resolution of symptoms when treated with acetazolamide (7 patients) or spironolactone (one patient). All experienced headache recurrence when tapering off medication, and none were able to completely taper off medication.

Discussion and take home points >

Discussion

The case series appears to identify a new subtype of chronic daily headache in overweight/obese women in their fifties and sixties. The Trendelenburg position, an indication of increased intracranial pressure, appears to be diagnostic. While the etiology remains unknown, it could be related to cerebrospinal fluid (CSF) pressure high enough above baseline to cause headaches, but not severe enough to cause disc edema.

Why these women developed increased CSF pressure is unknown but multiple causes may have worked together to cause the condition.

Increased BMI has been linked to elevated intracranial pressure. But weight alone may not be to blame, because not all women in this series were overweight or obese. Other contributing factors can include cerebral venous congestion, venous anomaly, and decreased estrogen levels causing cerebral venous insufficiency.

Other causes of increased CSF pressure were ruled out but include: intracranial mass lesions, venous thrombosis, vessel stenosis, jugular vein compression, decreased CSF absorption (eg, from past meningitis or intracranial hemorrhage), or increased CSF production (eg, from a choroid plexus lesion or malignant systemic hypertension).

Take Home Points

• This case series describes a possible new type of daily headache in middle-aged overweight or obese women
• Trendelenburg position appeared diagnostic, and indicated increased intracranial pressure
• All women responded well to CSF-pressure lowering medication
• The cause of increased CSF pressure was unknown; contributing factors could be increased BMI, hormonal factors, venous anomaly, and/or venous congestion

References:

1. Rozen TD. A new subtype of chronic daily headache presenting in older women. J Women’s Health (Larchmt). 2018;27:203-208.