Low pressure headaches caused by spontaneous intracranial hypotension

The bottom line

• Ask all patients with a new headache: “Is your headache made worse by changing posture from lying down to an upright position? Prominent postural features (pain worse when upright) should alert clinicians to the possible diagnosis of spontaneous intracranial hypotension

• If spontaneous intracranial hypotension is suspected and the patient is debilitated, magnetic resonance imaging of the head with gadolinium is the best investigation. It typically shows pachymeningeal enhancement, and features of brain “sagging” may also be seen on sagittal views

• Imaging evidence of subdural collections or brain sagging should trigger a review of the history in patients with headache if spontaneous intracranial hypotension has not previously been considered

• If conservative management is unsuccessful, epidural blood patch may relieve the headache

How patients were involved in the creation of this article

A patient recently diagnosed with spontaneous intracranial hypotension who also underwent a blood patch for the management of her condition wrote the patient perspective and gave permission for the magnetic resonance imaging scans to be included. Her comments on the draft manuscript have been incorporated in the revised paper. In particular, she highlighted that she was initially diagnosed with migraine and her postural symptoms were not appreciated. She wishes to raise awareness of the condition and its management.