Headache Secondary to Intracranial Hypotension

Abstract

Intracranial hypotension is known to occur as a result of spinal cerebrospinal fluid (CSF) leaking, which may be iatrogenic, traumatic, or spontaneous. Headache is usually, but not always, orthostatic. Spontaneous cases are recognized more readily than in previous decades as a result of a greater awareness of clinical presentations and typical cranial magnetic resonance imaging findings. An underlying disorder of connective tissue that predisposes to weakness of the dura is implicated in spontaneous spinal CSF leaks. CT, MR, and digital subtraction myelography are the imaging modalities of choice to identify spinal CSF leakage. Spinal imaging protocols continue to evolve with improved diagnostic sensitivity. Epidural blood patching is the most common initial intervention for those seeking medical attention, and may be repeated several times. Surgery is reserved for cases that fail to respond or relapse after simpler measures. While the prognosis is generally good with intervention, serious complications do occur. More research is needed to better understand the genetics and pathophysiology of dural weakness as well as physiologic compensatory mechanisms, to continue to refine imaging modalities and treatment approaches, and to evaluate short- and long-term clinical outcomes.

Atypical Presentations of Intracranial Hypotension: Comparison with Classic Spontaneous Intracranial Hypotension

“…This could result from structural weakness of the dura or insufficient physiologic adaptation to chronic CSF hypovolemia. 1 Atypical clinical presentations of SIH can be grouped into 4 domains: cognitive-behavioral, lower cranial nerve, imbalancegait, and arousal deficits. Typically patients present with a combination of these symptom complexes.…”

Spontaneous Intracranial Hypotension: 10 Myths and Misperceptions

“…20 When headaches are absent (termed the "acephalgic" form), auditory symptoms, such as muffled hearing or tinnitus, and ear pain or pressure are common complaints. Cervicogenic headache can also cause headache when upright due to axial loading of the spine, 22 and is often occipital in location. 3 Postural orthostatic tachycardia syndrome (POTS) has been well documented to cause orthostatic headache in some patients.…”

“…22,38 A frequent but under-reported complication of CSF leak closure is rebound intracranial hypertension (RIH). Furthermore, some patients may relapse after initial improvement, necessitating repeated treatment.…”

Management of a Ventral Cerebrospinal Fluid Leak With a Lumbar Transforaminal Epidural Blood Patch in a Child With Persistent Postdural Puncture Headache

“…In addition, it has been postulated that compensatory vasodilatation of cerebral vessels contributes to PDPH. [3][4][5] Because LP needles are inserted from the posterior of the spine, these dural leaks are generally located in the posterior aspect of the dura. 1,3,6 An epidural blood patch in the region of the presumed leak is a commonly used management technique for treatment of CSF hypotension.…”