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Response From Doepp

In their article “Migraine Aggravation Caused by Cephalic Venous Congestion” (Doepp F, Schreiber SJ, Dreier JP, Einhäupl KM, Valdueza JM. Headache. 2003;43:96-98), Doepp et al reported that 68% of patients with migraine experienced increased headache intensity when a Queckenstedt maneuver was performed with the patients supine. They concluded that the increased headache intensity was caused by intracranial venous distension. This conclusion may be incorrect. Schumacher and Wolff reported that by increasing intracranial pressure and thereby reducing intracranial vascular distension, they were able to reduce the intensity of the pain in histamine-induced headache.1 Increasing intracranial pressure did not, however, reduce pain intensity in patients with migraine. They concluded that the pain of migraine was not due to distension of intracranial vessels. Doepp et al make the assumption that in the upright position cerebral blood drainage occurs “via the intraspinal and extraspinal venous system.” Principal outflow through the internal jugular veins can indeed be substituted completely by the large vertebral plexus through communications at the cranial base.2 One would have to ask why this happens when the patient is upright, but not when the patient is supine. There should be adequate drainage even when the jugular veins are occluded.