This headache is also known as intracranial hypotension, low-pressure headache, or headache attributed to CSF (cerebrospinal fluid) leak.. It is characterized by its worsening upon standing (orthostatic) and walking, and improving or resolving when lying down. This is caused by low CSF pressure (intracranial hypotension), usually from CSF leakage. It is often accompanied by ringing in the ears (tinnitus), neck pain, hearing changes, sensitivity to light (photophobia) and/or nausea.
These symptoms resolve quickly after normalization of CSF pressure and sealing of the CSF leak. It is diagnosed by a low CSF pressure (less than 6 cmH2O, or 60 mm CSF) on lumbar puncture and/or evidence of a CSF leak on neuroimaging (starting with a brain MRI with contrast). If a CSF leak is suspected based on history and/or MRI, the next step is to try to identify the leak site. The least invasive way for this (which doesn't require a lumbar puncture such as CT myelogram or nuclear medicine studies) is a spinal MRI with CSF leak protocol (heavily weighted T2 imaging), and no contrast is needed. This is often very helpful at looking for pockets of leaked CSF along the spine to determine the spinal level that needs a blood patch.
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