Cerebrospinal fluid (CSF) leak headache
A cerebrospinal fluid (CSF) leak headache, also known as spontaneous intracranial hypotension (SIH), is a distinct type of headache caused by a reduction in the volume or pressure of cerebrospinal fluid surrounding the brain and spinal cord. CSF serves as a cushioning fluid for the brain and spinal cord. If it were to leak (typically due to a tear or hole in the dura mater), the resulting pressure change can trigger intense headaches. These headaches often develop after procedures like a lumbar puncture, spinal surgery, heavy exertion, or even spontaneously without an identifiable cause.
One of the hallmark symptoms of a CSF leak headache is its positional nature. The headache typically worsens when the person is standing or sitting upright and greatly improves when lying down. This is due to gravity’s effect on CSF pressure. The pain is usually described as a dull, throbbing sensation in the back of the head or neck, though it can vary in intensity and location. Associated symptoms may include neck stiffness, nausea, dizziness, visual disturbances, or even changes in hearing, such as ringing in the ears or a sensation of fullness. It is common they are misdiagnosed as migraine or tension headaches
Diagnosis often involves a detailed medical history, physical exam, and imaging studies. MRI of the brain with gadolinium contrast can sometimes reveal indirect signs of a CSF leak, such as brain sagging or enhancement of the meninges. For further confirmation, additional imaging such as spinal MRI or CT myelography are able pinpoint the exact location of the leak.
Treatment depends on the cause and severity of the leak. Conservative measures like bed rest, increased hydration, and caffeine intake may help mild cases resolve on their own. In more persistent or severe cases, an epidural blood patch (where the patient’s own blood is injected into the epidural space to seal the leak) is can be effective. Surgical intervention is rarely needed but may be required in complex or recurrent leaks. Early recognition and appropriate treatment of a CSF leak headache can significantly improve a patient's quality of life and prevent complications. If you feel you may be suffering from a CSF leak headache, be sure to contact your neurologist or headache specialist.