Site of Dural Arteriovenous Fistula Linked to Clinical Features of Headache

dural arteriovenous fistula
This lateral image from a conventional cerebral angiogram of a child shows a dural arteriovenous fistula between the anterior meningeal branch of the ophthalmic artery and the superior sagittal sinus. These are high flow vascular malformations that can cause neurologic deficits, headaches, seizures and intracranial bleeding.
Researchers found an association between the site of dural arteriovenous fistulas and headache characteristics.

There is an association between the site of dural arteriovenous fistulas (DAVFs) and headache characteristics, as carotid-cavernous fistulas may be accompanied by ocular symptoms and non-migraine-like headache, whereas migraine-like headaches are more common with other DAVFs, according to study results published in The Journal of Headache and Pain.

According to the researchers, DAVFs are intracranial vascular malformations fed by dural arteries and draining venous sinuses or meningeal veins. The etiology is not clearly understood, the clinical course varies widely, and there are various treatment options, including conservative, endovascular, surgical, or stereotactic radiosurgery approaches.

The goal of the current study was to report a 10-year single-institution experience with diagnosed and/or treated DAVFs, including the clinical presentation and headache characteristics, location, treatment, and long-term outcome. Modified Rankin Scale was used to assess the long-term outcomes.

The study cohort included 42 DAVFs in 40 patients (ages 25-89 years, 52.5% women). Of these, 42.9% were located at the transverse sigmoid junction, 33.3% in the carotid-cavernous area, 14.3% in the anterior cranial fossa, 7.1% in the tentorial area, and 2.4% in the superior petrosal sinus.

Migraine-like headache were more characteristic of DAVFs other than carotid-cavernous fistulas (42.3% vs 7.1%, respectively; P =.036), whereas nonmigraine headache was a typical characteristic of carotid-cavernous fistulas (42.9% vs 0%, respectively; P =.003). The side of the headache was ipsilateral to the side of the fistula in all non-migraine-like headaches, whereas in migraine-like cases, there was no correlation between DAVF location and side of headache.

Ocular symptoms were more common among patients with carotid-cavernous fistulas compared with all other DAVFs (92.9% vs 7.7%, P <.001), including diplopia (78.6% vs 0%, respectively; P <.001), exophthalmos (35.7% vs 0%, respectively; P =.003), and hyperemia/conjunctival chemosis (64.3% vs 0%, respectively; P <.001).

Of 32 patients with available long-term data, 70% did not report any consequence in quality of life because they were asymptomatic or without significant disability (modified Rankin Scale score of 0 or 1). One patient died due to intracranial hemorrhage 2 years after the diagnosis of DAVFs.

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The researchers acknowledged several study limitations, including the small sample size, selection bias secondary to the use of clinical-based samples rather than population-based samples, and possible recall bias.

Researchers concluded that although their findings are in line with previous clinical studies on DAVFs, this study “provides new significant insights on headache and its characteristics as a presentation symptom in DAVFs.”


Corbelli I, De Maria F, Eusebi P, et al. Dural arteriovenous fistulas and headache features: an observational study. J Headache Pain. 2020;21(1):6. doi: 10.1186/s10194-020-1073-1