Migraine aggravation caused by cephalic venous congestion

Background.-Cerebral venous distension is thought by some to serve as a source of migraine pain. Previous investigators have tried to modify pain intensity by induction of additional venous congestion via compression of both internal jugular veins (Queckenstedt's maneuver). The magnitude of blood flow within the internal jugular veins depends markedly on body position, and inconsistencies in positioning may have influenced their results. Objective.-To investigate the effect of Queckenstedt's maneuver, performed both in the upright and in the supine body position, in migraineurs during an acute attack. Methods.-Twenty-five patients (18 women, 7 men; mean age +/- SD, 35.4 +/- 13.3 years) with International Headache Society-defined migraine without aura were evaluated. Queckenstedt's maneuver was performed in both body positions during an acute migraine attack, involving constant application of manual pressure to both internal jugular veins for 30 seconds. Headache intensity was rated before, during, and after Queckenstedt's maneuver on a scale extending from 1 (mild) to 10 (intolerable). Results.-Seventeen patients (68%) reported an increase of headache intensity in the supine position during Queckenstedt's maneuver. In the sitting position, pain increase was observed only in 6 patients (24%). The magnitude of pain increase was significantly greater in the supine position compared to the upright position (P = .02). Conclusions.-Our results support a role for cerebral venous congestion in the generation of migraine pain and suggest body position may influence the clinical expression of that process.