Headache Treatments
Michael A. Rogawski, M.D., Ph.D.
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High and Low Pressure Headache

Friedman DI. Headaches Due to Low and High Intracranial Pressure. Continuum (Minneap Minn). 2018 Aug;24(4, Headache):1066-1091.

Idiopathic Intracranial Hypertension (IIH)

  • Headache worsens on awakening
  • Pulsatile tinnitus
  • Papilledema

Low Pressure Headache

Occur on rising and/or later in the day

​Headache triggered by standing. In clinic, put patient in Trendelenburg (the body is laid supine, or flat on the back with the feet higher than the head by 15-30 degrees) 10 min, headache should resolve. Intracranial Spinal CSF leak, spontaneous or trauma (may be trivial) or valsalva. Ehlers-Danlos or joint laxity. Fragile dura. Brain MRI with contrast: dural thickening, brain sag. Do not confuse with Chiari malformation. Don't do LP routinely; if you do, use small needle, 24 gauge. Low pressure not always present: <60 mm. Cervical cord or thoracic cord. Identification of leak: CT and MR myelogram (intrathecal gadolinium, off label use). 
Leak in the Spinal Column, Most Often Low Cervical or Thoracic

Website for Patients
https://spinalcsfleak.org/

Key Factors
  • Postural, end-of-the-day, and Valsalva components to the headache are present
  • Joint hypermobility
Typical Characteristics
  • Orthostatic or gets worse at end of day. (Longer patient has SIH, the less likely there is a postural component.)
  • Majority of patients are awakened by headache in middle of night.
  • Headache is often exertional and worsens with Valsalva including coughing, sneezing, lifting, bending forward, straining, singing, or sexual activity.
  • Caffeine often works very well.
  • May be thunderclap in onset but not necessarily.
Other Symptoms
  • Tinnitus
  • Abnormal hearing as if underwater
  • Neck pain, imbalance
  • Pain between shoulder blades
  • Blurred or double vision.
Most common location is posterior, but pain can be centered anywhere in the head or face.
Bilateral more common than unilateral.

Risk factors: joint hypermobility, previous lumbar puncture, epidural or spinal anesthesia, known disc disease, or a personal or family history of retinal detachment at a young age, aneurysm, dissection, or valvular heart disease.

Physical Examination
  • Joint hypermobility
  • Spontaneous retinal venous pulsations indicative of normal CSF pressure are present in the eyes
  • Put patient in 5 degrees of Trendelenburg position for 5-10 minutes to see if that improves the headache and other symptoms.
Diagnosis
  • Brain MRI with gadolinium enhancement (normal in 30% of affected patients)
  • No consensus when the brain MRI is negative. Can do (1) CT with or without MR myelography, or (2) T2-weighted spine MRI. (No leak is found in about half of individuals with SIH.)
Treatment
Conservative measures don’t work very well. Even if a leak site hasn’t been identified, treat with a high-volume epidural CT-guided targeted blood patch with fibrin sealant. (Relief about a third of the time each time you do it)
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