Case Presentation: A 41 year old female with a history of Hypertension, Hyperlipidemia, Morbid obesity, and Prediabetes presented with a six week history of daily, frontal, pressure-like, positional headaches exacerbated by standing with associated nausea and vomiting. Patient’s medication list included Metformin, Semaglutide, Losartan, and Fexofenadine. Given minimal resolution with over the counter analgesics Magnetic Resonance Imaging (MRI) of the brain was performed showing thin diffuse chronic appearing subdural collections and possible intracranial hypotension. MRI complete spine revealed extradural fluid signal in the cervical canal and posterior fossa with an intrinsic hemorrhagic/proteinaceous component with fluid level in the posterior fossa extra-axial space as well as extradural fluid throughout most of the thoracic and lumbar spine without a clear source of CSF leak. Neurosurgery was consulted and Computed Tomography (CT) complete spine myelography showed extradural contrast into the left neural foramina at L1 to L4, most pronounced at the L3-4 space with frank extravasation of the contrast into the paraspinal soft tissues along the medial margin of the left psoas muscle confirming site of CSF leak. Patient underwent a lumbar epidural blood patch which was well tolerated with significant improvement in her headaches.

Discussion: The evaluation of headaches begins with a thorough history and emphasis on red flag signs and symptoms in order to evaluate for secondary causes such as hemorrhage, infectious, rheumatologic, neoplastic and traumatic. Spontaneous intracranial hypotension (SIH) is an uncommon etiology of secondary headache due to the presence of low CSF volume from a dural tear resulting in CSF leakage. In contrast to the commonly diagnosed post-dural puncture headache, SIH is suspected to be underdiagnosed due to the frequent absence of a clear cause. Clinical presentation may consist of orthostatic headaches, nausea, vomiting, visual disturbances , vertigo and tinnitus. Diagnosis is made using MRI with contrast which shows subdural fluid collections, meningeal enhancement, engorgement of venous structures and sagging of the brain. However, identification of the precise location of CSF leak requires use of CT myelography. Untreated SIH can lead to numerous complications including subdural hemorrhage, subarachnoid hemorrhage, dural sinus thrombosis, cranial nerve palsies and coma. SIH may be managed conservatively , non-surgically or surgically. Conservative treatment with bed rest, hydration and caffeine intake can be trialed followed by non-surgical techniques, namely targeted epidural blood patch (EBP). In the event of headache recurrences, repeat EBP or use of fibrin sealant can be considered. Neurosurgical repair is usually a last resort after failure of conservative and non-surgical measures or the presence of severe complications.Our patient presented with the hallmark features of SIH, orthostatic headaches with classic MRI findings and localization of CSF leak via CT myelography. EBP was performed due to failure of conservative management and significant functional impairment. The patient had rapid resolution of symptoms post procedure.

Conclusions: The ability to recognize postural or orthostatic headaches is of utmost importance to prevent functional impairment and life threatening complications associated with SIH. Early identification of red flag symptoms can prevent diagnostic delay, thus improving morbidity and mortality in patients with SIH.