Background: Cerebral venous sinus thrombosis (CVST) is an uncommon cause of stroke. Headache is the most common symptom in CVST, however the mechanism of headache and its treatment are presently unclear. We report a patient with CVST whose headache clinically resembled migraine. We propose pathophysiological similarity between common migraine and CVST-related headaches.
Case summary: A 25-year-old male developed severe right hemicranial, throbbing headache for 15 days. The headache was worse with routine activities, associated features included: nausea, vomiting, photophobia and phonophobia. Examination revealed bilateral papilledema and right lateral rectus palsy. Magnetic resonance imaging of the brain with susceptibility-weighted imaging (SWI) demonstrated prominent right hemispheric veins (venous congestion) with thrombosis of right frontal cortical vein, superior sagittal, right transverse, and sigmoid sinus. The patient’s headache responded excellently to intravenous mannitol infusion and vascular decongestion was proven on repeat SWI. He was treated with unfractionated heparin, followed by oral anticoagulation.
Conclusion: Our patient’s headache met many of the clinical criteria for migraine. Vascular congestion on SWI has been reported in migraine with aura and CVST. The clinical-imaging resemblance suggests a possible shared mechanism of headache between migraine and CVST. Activation of the trigeminovascular system could be an important link. Activation of the trigeminovascular system could be caused either by blood products in cortical veins/dural sinus or vascular congestion. We suggest that migraine/nonmigraine medications with vaso/venoconstrictor effects could benefit CVST associated headache eg. Ergots, indomethacin and mannitol.

HEMICRANIAL HEADACHE IN CEREBRAL VENOUS SINUS THROMBOSIS: ROLE OF TRIGEMINOVASCULAR SYSTEM