Diagnosis and Treatment

AVM-associated headache may or may not present with other symptoms. “Intractable, unilateral headache should increase suspicion for brain AVM and prompt [magnetic resonance imaging] MRI evaluation,” according to the review.8 According to the International Classification of Headache Disorders (ICHD-3) diagnostic criteria for AVM-related headaches, they “have a clinical course that parallels that of a coexisting AVM in terms of temporality, severity, and location.” 

The most well-known example is occipital AVM, which is believed to be a risk factor for headache. Headache occurs in patients with occipital AVM at rates ranging from 15% to 61%, and it is often characterized by visual symptoms such as field cuts and blurring, as well as other migraine-like symptoms.12-14

If AVM is detected, the Spetzler-Martin grading system can help estimate risk and guide treatment selection, which is influenced by the size, location, blood vessel supply, and drainage of the AVM. Grading is based on a 1 to 5 scale, with 1 representing the simplest cases and 5 representing the most complex cases. A 2010 study observed surgical risk levels ranging from 0.7% (95% CI, 0%-3%) in grade 1-2 AVMs to 21% (95% CI, 15%-28%) in grade 3-5 AVMs.15

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If lesion eradication is identified as the treatment goal, it may be achieved by several methods. Various “case series have shown that intervention for AVM with microsurgical resection, endovascular embolization, stereotactic radiosurgery, or a combination of these can be effective in decreasing or even eliminating headaches –however, there could be bias in case reporting,” said Dr Kung.

  • Microsurgical resection, embolization, or both led to significant or complete headache improvement across a number of studies in 39% to 100% of patients.16,17
  • Radiosurgery shows improvement rates ranging from 47% to 75% across numerous studies, including a retrospective study demonstrating a 69.5% headache reduction 5 years after radiosurgery for AVM.18-20
  • Multimodal treatment, such a combination of surgery, embolization, and/or radiosurgery embolization, was associated with improvement in 50% to 67% of cases in earlier research, and the improvement rate was 87.8% in a new study of multidisciplinary care for AVM-associated headache.21  

Future Directions

Research on AVM has mainly focused on hemorrhage risk vs treatment risk, as well as seizure control, rather than headache. “There is a lot we don’t know about AVM-related headache,” said Dr Kung. “I believe that the next step should be to study the effect of pharmacological agents on achieving headache relief for unruptured AVM, targeting each hypothetical mechanism.” 


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