Internal jugular vein valve incompetence: A key consideration in patients with exercise-induced headache

We read the review titled ‘Update on headaches associated with physical exertion’ by González-Quintanilla et al. ¹ with great interest. We commend the authors for their valuable contribution to the field, which will undoubtedly benefit clinicians.

However, we believe the paper, particularly the diagnostic and therapeutic algorithm for exertional headache shown in their figure 3, overlooks the potential role of internal jugular vein valve incompetence (IJVVI) as a cause of exercise-induced headache. In addition to isolated reports,^2–4 several studies support this claim. One study comparing the prevalence of IJVVI in patients with primary exertional headaches versus age-matched controls, using duplex ultrasound, found a statistically significant difference (70% vs. 20%). ⁵ This underscores the importance of considering IJVVI in diagnostic evaluations, given its pathophysiological implications and the potential for new treatment avenues.

Doppler ultrasound, a non-invasive and widely available technique, demonstrates high specificity and sensitivity when performed by experienced radiologists. Its affordability and accessibility further support its use in evaluating patients with this type of headache (for an example, see Figure 1).

Figure 1.

Doppler ultrasound showing reversed flow in the right internal jugular vein during the Valsalva maneuver in an 18-year-old male with exertional headaches triggered by strenuous isotonic exercise. Brain MRI was unremarkable. The patient was referred to a physiotherapist for exercise guidance, and the headache did not recur.

Therefore, we recommend that young patients with exertional headaches, normal neurological exams, and normal angio-magnetic resonance imaging undergo duplex ultrasound of the internal jugular veins at rest and during the Valsalva maneuver to rule out IJVVI.

Additionally, for future research, we propose introducing distinct codes (A4.1.1 and A4.1.2) to the International Classification of Headache Disorders. ⁶ These codes would differentiate between primary exertional headache with and without evidence of IJVVI until a clearer understanding of this condition is established.