A 62 year-old, previously well, Caucasian woman presented to hospital with an acute onset, moderate intensity headache after lifting a heavy object while bending down. The headache lasted 15 minutes and was bilateral over the vertex, without photophobia, motion sensitivity, nausea or autonomic symptoms. As she had previously never had headaches, she sought medical attention. Neurological examination was normal, CT brain illustrated no acute bleed and magnetic resonance angiogram (MRA) was normal. A magnetic resonance imaging (MRI) scan showed type 1 Arnold-Chiari malformation (Fig 1) (the position of the cerebellar tonsils can be seen below the foramen magnum). A normal MRI scan (Fig 2) is shown for comparison. Valsalva headache secondary to Arnold-Chiari malformation was diagnosed. After 18 months her headaches remained rare and mild, so no further intervention has yet been needed. While uncommon, headaches caused (rather than exacerbated) by Valsalva or coughing require an MRI as posterior fossa lesions are found in nearly half of all cases. Arnold-Chiari malformations are the most common and may need surgical decompression.
T1 sagittal brain MRI of patient with type 1 Arnold Chiari malformation with cerebellar tonsils below the foramen magnum (shown by red line). MRI = magnetic resonance imaging.
T1 sagittal brain MRI of normal subject. MRI = magnetic resonance imagine.
- © 2013 Royal College of Physicians
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