Laugh-induced Headache: Clinical Features and Literature Review

Ye Ran, MD; Huanxian Liu, MD; Meichen Zhang, MD; Zhao Dong, MD, PhD; Shengyuan Yu, MD, PhD

Headache. 2017;57(10):1498-1506.

Abstract and Introduction

Abstract

Background. Laughing is a rare precipitating factor for headaches, and the pathogenesis underlying laugh-induced headache (LH) remains unclear.

Methods. Two cases of headache triggered predominantly by laughing were presented in this article. We also reviewed the published English literature regarding LH, summarized the clinical characteristics of LH, and discussed the probable pathophysiological mechanisms.

Results. In the first patient, magnetic resonance imaging of the brain revealed cerebellar tonsillar herniation through the foramen magnum. In the second patient, we did not find any evidence of intracranial disease. The literature review showed that LH is a mild to severe, non-pulsating headache. In most cases, the duration of each attack was limited to a few minutes. The headache usually bursts after laughing and reaches its peak almost immediately. In some cases, the headache can only be induced by mirthful laughing rather than by fake laughing.

Conclusion. LH can be categorized as primary LH and secondary LH. Changes in the spatial structure in the posterior cranial fossa and cerebrospinal fluid circulation may contribute to the development of secondary LH. Primary LH, primary cough headache, and primary exercise headache may share some common pathogenesis. And we speculate that the regions of the brain associated with the expression of mirth might be associated with LH.

Introduction

There are many triggers of headaches, including weather changes, stress, menses, missed meals, glare, oversleeping, perfumes, cigarette smoke, and sexual activity.^[1,2] Laughing has also previously been reported as a trigger of headache. In 1956, Symonds^[3] reported 21 patients who had severe headache precipitated by coughing, laughing, sneezing, straining to defecate, or stooping. In this article, we presented two patients with headache triggered by laughing. We also reviewed previous reports of similar cases to summarize the characteristics of laugh-induced headache (LH) and investigated the probable pathogenesis of this specific clinical phenomenon.

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Abstract and Introduction
Methods
Results
Discussion
Conclusion
References
Sidebar

Table 1. Clinical Features of Patients With LH
					Clinical Features of Headache Induced by Laugh
	Source	Sex	Age of Onset	Headache History	Characteristic	Location	Triggers	Mode of Onset	Duration of Each Episode	Associated Symptoms	Brain MRI	Treatment	Remarks
Secondary LH	Patient 1	F	32	None	Intense	Bilateral parietal, occipital	Laughing, bending	Reached peak immediately	10 seconds	None	Cerebellar tonsillar herniation through the foramen magnum	Avoided triggering factors
	Morales-Asin et al⁵	F	44	None	Excruciating pain	Vertex	P. 1: Laughing, yelling, straining to defecate	N.A.	P. 1: 10–20 seconds	None	Cerebellar tonsillar herniation through the foramen magnum and mild basilar impression	Refused neurosurgical consultation	She reported an exercise-induced headache at 8 years following the initial instance
							P. 1: Laughing, yelling, straining to defecate		P. 2: 10–15 minutes
							P. 2: Exertion		P. 2: 10–15 minutes
	Boga et al⁴	M	26	None	Severe	Occipital	Hearty laugh	Lightning-sharp pains	5–10 seconds	None	An enhanced mass lesion in the inferior half of the fourth ventricle produced mild dilatation of the lateral and fourth ventricles, and the cerebellar tonsils were herniating through the foramen magnum to the level of the arch of the first vertebral body	Tumor resection with posterior fossa decompression followed by radiotherapy
	Reeder et al⁶	M	46	Not available	Severe	N.A.	Laughing, coughing	N.A.	N.A.	None	Cerebellar tonsillar herniation through the foramen magnum	Analgesic therapy
		F	16	Not available	Severe	Occipital	Laughing, coughing	N.A.	N.A.	Horizontal nystagmus on downward gaze, bilateral hyperreflexia	Cerebellar tonsillar herniation through the foramen magnum	Analgesic therapy
	Giraud et al⁷	F	52	None	Intense, nonpulsating	Whole head or occipital area	Laughing, sneezing, coughing	Reached peak immediately	4–5 minutes	None	Presence of GPGs in the right and left transverse sinuses and in the superior sagittal sinus	Weight loss	Her sister and one of her nephews also suffered headache induced by laugh to a lesser extent
Primary LH	Patient 2	M	19	None	Mild to intense non-throbbing	Bilateral occipital	Exercising, laughing	Reached peak immediately	Within 1 minute	None	Normal	Indomethacin
	Levin et al⁸	M	45	Migraine for many years	P. 1: Severe, lancinations	P. 1: Posterior	P. 1: Hearty laugh, weight lifting	Reach peak immediately	10 seconds	None	Normal	Divalproex sodium (500 mg) twice daily	LH did not recur during the following 2 years
					P. 2: Excruciating	P. 2: Bilateral posterior	P. 1: Hearty laugh, weight lifting
					P. 2: Excruciating	P. 2: Bilateral posterior	P. 2: Moderate mirthful laugh, occasionally cough
	Shatti et al⁹	F	46	None	Pressure like	Left sided	Mirthful laugh	N.A.	Lasting most of the day	Kaleidoscopic visual, photophobia, nausea	Normal	Nortriptyline	Shortly prior to onset, she had suffered a minor whiplash injury following a road traffic accident

F, female; M, male; N.A., not available; P. 1, phase 1; P. 2, phase 2.

Table 2. Comparison of LH, PCH, and PEH
	Primary LH	Secondary LH	PCH	PEH
Triggers	Mirthful laugh, occasional exertion behavior	Laughing, bending, coughing, straining, sneezing, or other Valsalva maneuvers	Coughing, straining, or other Valsalva maneuvers	Strenuous physical exercise
Mode of onset	Sudden onset	Sudden onset	Sudden onset	During or after exercise
Mode of onset	Reaches its peak immediately	Reaches its peak immediately	Reaches its peak immediately	During or after exercise
Duration	Lasting within 1 minute or most of the day	Lasting between 1 second and several minutes	Lasting between 1 second and several minutes	Subsides when the activity ceases, occasionally lasts up to 48 hours
Character	Nonthrobbing	Nonthrobbing	Sharp, stabbing, splitting, or even explosive quality	Mostly pulsating
Location	Bilateral posterior or hemilateral	Bilateral and posterior areas	Maximal in the occipital region	Bilateral or unilateral
Associated symptoms	Have been reported in one patient (kaleidoscopic visual, photophobia, and nausea)	None	Vertigo, nausea, and sleep abnormality	Nausea, vomiting, photophobia, and phonophobia
Treatment	Indomethacin, divalproex sodium, or nortriptyline	Surgical operation	Indomethacin	Indomethacin or ergotamine tartrate