Venous congestion headaches | Intracranial hypertension headache

Ross Hauser, M.D.

The most common complaint we see for head pain is head pressure that won’t go away. Typically we see people that explain that when they go to their doctors, they describe a head pressure that causes them headaches. They are then prescribed  medications. Many are in our center because the medications did not help them. In many of these people we speculate that if the medications are not alleviating their headaches, the patient should have a musculoskeletal cause (neck instability) for their headaches explored.

In testing on our patients, we find that the number one structural cause that they suffer from is compression of the jugular veins. The jugular veins are the main drainage port for the brain. Seventy percent of the fluid in the brain is in the venous system (the drainage system that removes wastes from the body and brings deoxygenated blood back to the heart to be re-oxygenated.) While the jugular veins themselves are very large, the other veins of the network can be very small. Some of these smaller brains can be compressed by the bones of an unstable neck.

Potential symptoms from internal jugular vein compression

When the volume of Cerebrospinal fluid (CSF) increases due to obstruction of CSF flow or absorption, the intracranial pressure increases. This can cause headaches, vomiting, fatigue, back pain and visual disturbances. These are symptoms that occur in many of the conditions discussed with cervical instability including post-concussion syndrome (PCS) and whiplash associated disorders (WAD). One of the clues that the head has increased ICP is a morning headache which may awaken one from sleep. This is believed to occur because cerebral edema is worse during the night due to the supine position. Other clues are that the headache is worse with coughing, sneezing and bending, all of which increase intracranial pressure. Sometimes there are also personality changes. Typically, conditions which involve increased ICP worsen over time, so the symptoms get worse.

Headache, head pressure, eye pain, dizziness, anxiety, visual snow, distorted vision, afterimages, seasickness feeling, unstable visual field, depression depersonalization, brain fog, focusing issues, and hormone imbalance.

Potential symptoms from internal jugular vein compression

If a person has a breakdown of their neck curve caused by cervical neck instability which in turn is causing compression on the jugular veins and the symptoms of headache remain even when they are laying down (when symptoms should be relieved), the person may find themselves in a situation where their headaches become “perplexing,” and a mystery to their doctors. Most of the time headaches do get better when you lay down. If they do not, a significant breakdown of the normal neck structure should be considered as the culprit of jugular vein compression and a lateral x-ray should be taken to assess the structure of the neck.

When you research intracranial hypertension, you will find older articles refer to this problem as pseudotumor cerebri. Pseudotumor means symptoms that mimic a brain tumor. The new terminology is idiopathic intracranial hypertension is called IIH. Idiopathic means the doctors do not know the cause. In many patients we see we discover that the cause of their symptoms and headaches are caused by cervical spine instability causing venous compression.

Brain venous sinus outflow obstruction.

The venous system is susceptible to compression because unlike arteries they are devoid of a strong muscular wall. The cranio-vertebral venous system is devoid of valves, so depends on the pressure gradient between the arterial influx and the venous outflow tract. The internal jugular vein is easily compressed, as only a very gentle pressure to the neck causes intracranial hypertension to rise.  When bilateral internal jugular veins are compressed by gentle pressure it is called the Queckensted’s maneuver and can be used to see if venous congestion is part of the pathophysiology of a condition. For instance, in Migraine’s, the Queckenstedt’s maneuver increases pain.(1)

This condition is called venous dysgemia which can lead to intracranial hypertension and result in brain cortex hypoperfusion (reduced blood flow) and brain cell death or brain atrophy.

Symptoms and conditions of cervical spine compression causing internal jugular vein stenosis

What are we seeing in the image below?

Below is an image from a 1940 medical paper (2) that was used as a demonstration of where headaches developed in the cerebral venous sinus in a 2016 medical paper by Dr. Mark H. Wilson of  Queen Mary College, London. The 2016 paper was published in the Journal of Cerebral Blood Flow and Metabolism. (3)

What Dr. Wilson pointed out was “They (the 1940 researchers) demonstrated that pressure on the sinuses caused significant headache pain.” Further, the pain caused by venous structures has largely been forgotten by doctors.

Basically, the image shows that when you have venous tension in the brain, there are various headaches are produced. This image shows that if you have compression of the jugular veins it’s going to cause venous hypertension in your brain and that can cause many types of headaches. Most people we see don’t complain of a “whole head” pain.  Many people have certain parts of their heads where they get their common headaches.

Trigeminal neuralgia? Intracranial hypertension headache? Both

What perhaps isn’t appreciated enough in pain management is the fact that structural abnormalities such as upper cervical instability can cause nerve stimulation to cranial nerves and even blood vessels, causing headaches. In our many years of helping people with chronic pain, we have seen many people with a diagnosis of trigeminal neuralgia. For some of these people, possibly including yourself, it was not easy getting this diagnosis as these people displayed symptoms that can be assessed and attributed to many other health challenges. The trigeminal nerve carries pain, feeling, and sensation from the brain to the skin of the face. Trigeminal neuralgia means trigeminal nerve pain.

Doctors consider it rare that a patient suffers from trigeminal neuralgia headache with idiopathic intracranial hypertension. An October 2023 paper from Ege University Faculty of Medicine (4) a 56-year-old female patient was admitted to their center with the complaint of “jabbing pain that may feel like an electrical shock on the right side of her face.” The patient was diagnosed with trigeminal neuralgia eight years prior. “She had a lightning-flashing pain in the area corresponding to the right mandibular nerve (center). Her pain attacks lasted one to two minutes, and recurring 15-20 times during the day.”

Extensive MRI and imaging testing revealed finding compatible with intracranial hypertension. As a result, based on these findings, “the patient was diagnosed with TN or trigeminal neuropathy accompanying intracranial hypertension headache.”

Sometimes the blockage of CSF flow is so bad that a shunt has to be placed in the brain’s lateral ventricle. This type of drain is known as an extraventricular drain.

In September 2023, doctors at the Cleveland Clinic Florida, Department of Neurosurgery reported (5) on a 34-year-old female patient suffered from “typical trigeminal neuralgia right-sided facial pain that had started 7 years prior. “The patient described the pain as recurrent and electric shock-like . . . lasting for a few seconds, with increasing severity (made worse or sparked by) brushing teeth, chewing, or talking. In addition to facial pain, the patient complained of intermittent episodes of diplopia, blurred vision, and throbbing headaches. ” The patient also had rapid weight gain of 30 pounds. In this case the patient was eventually diagnosed with intracranial hypertension. Treatment with acetazolamide failed to improve her vision problems. The patient was recommended to a ventriculoperitoneal shunt procedure and remained on carbamazepine 1200mg daily for trigeminal pain following the procedure. Two weeks after the surgery, she reported an improvement in visual symptoms and significant relief of her facial pain.” In this case, her doctors point to a possible association between intracranial hypertension and Trigeminal neuralgia. Symptoms suggest that trigeminal neuralgia manifestation in these patients may involve pressure and damage to trigeminal nerve from increased intracranial pressure.


1 Doepp F, Schreiber SJ, Dreier JP, Einhäupl KM, Valdueza JM. Migraine aggravation caused by cephalic venous congestion. Headache: The Journal of Head and Face Pain. 2003 Feb;43(2):96-8. [Google Scholar]
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