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It is very common for patients with intracranial
hypotension due to a spinal CSF leak to be misdiagnosed
with migraine headache, cervicogenic headache,
occipital neuralgia, or other headache disorders.
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The Headache
The most common symptom associated with intracranial hypotension is an “orthostatic”
or positional headache. When the patient rises from lying flat, the pain often worsens
within seconds to hours and improves with lying flat again. When severe, the patient
may be unable to raise their head even one inch off the bed or may need to position
their head lower than their spine for relief. This positional aspect ten ds to be more
abrupt soon after the onset of the leak, and may become less evident over time. The
headache may evolve into a “second-half-of-the-day headache” or a chronic daily
headache without an obvious postural component. It is very common for patients with
intracranial hypotension due to a spinal CSF leak to be misdiagnosed with migraine
headache, cervicogenic headache, occipital neuralgia, or another headache disorder.
Usually, the headache is daily but in some cases, may be intermittent. The pain is
located most often at the back of the head, but may be at both temples, across the front
of the head, or all over the head. Severity can range from mild to excruciating. The
headache quality may be variably described as pulling, pressure, or throbbing.
Some patients remain quite functional despite their symptoms while others have
very limited ability to be functional when sitting or standing upright. Patients may be
largely bedridden. The degree of disability is often under-appreciated.
Headache is not universally prominent or even present. A range of other symptoms
may be more troublesome than head pain for a subset of patients.
Other Symptoms
Patients with intracranial hypotension often report neck pain or stiffness, nausea with
or without vomiting, pain or tightness between the shoulder blades, sense of being off
balance, changes in hearing, dizziness or vertigo, sensitivity to light or sounds, cognitive
difficulties, as well as arm pain or numbness. Less commonly reported symptoms include
visual changes, facial pain or numbness, fatigue, changes in taste, pain at nerve root
levels below the shoulders, or fluid discharge from the nipples. More rare presentations or
complications include unsteady gait, tremor, dementia, quadriplegia, stroke, stupor/coma, and
very rarely, death.
www.headaches.org
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National Headache Foundation
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