Case Presentation: A 31-year-old male presented with severe, progressive occipital headache that started four weeks ago. The headache was worse on standing and sitting up and relieved by lying flat. Associated symptoms included nausea, vomiting, tinnitus and blurry vision. A complete neurological exam including cranial, spinal, fundal, upper and lower limb examination was normal with no signs of meningism except for the symptoms described above. He reported experiencing a fall from a 20 feet height six weeks prior to presentation: he denied head trauma but reported severe lumbar back pain after he fell on his back. This was his first hospital presentations since the fall. His past medical history was otherwise insignificant, no previous history of migraines or headaches, no infectious symptoms or sick contacts. Neurology were consulted and concerned by the orthostatic nature of the headache, requested MRI brain imaging and spine imaging. MRI of the brain with gadolinium contrast was performed and showed pachymeningeal enhancement, subdural fluid collection, sagging of the brain and distended venous sinuses: findings sensitive and specific for a diagnosis of IH [4]. Spinal X-ray showed compression fractures of L1 and L3 vertebral bodies. Putting together the patient’s orthostatic headache, MRI brain findings and traumatic lumbar spine fracture; a diagnosis of IH was made. In this case, CSF leak from a spinal dural tear likely secondary to traumatic lumbar spine fracture could have been the underlying cause. The International Classification of Headache Disorders diagnostic criteria for IH was used to support the diagnosis. The patient was initially treated with bed rest, IV fluids, anti-emetics, analgesia and oral caffeine for symptomatic relief. Symptoms failed to resolve and definitive treatment with an epidural blood patch was performed. 20ml of the patient’s blood was injected into the epidural space to patch the hole in the dura. Within hours of epidural blood patch procedure, prompt resolution of the patient’s postural headache and associated symptoms was seen.
Discussion: The diagnosis of intracranial hypotension (IH) requires awareness of its characteristic features: progressive, persistent, postural headache associated with vestibular, cochlear, ocular and/or musculoskeletal symptom. Diagnostic criteria such as the Schievink criteria or International Classification of Headache Disorders diagnostic criteria can aid with the diagnosis [3,4]. There are sensitive and specific brain MRI signs [3,4]. The first steps in management include symptomatic treatment with bed rest, IV fluids, anti-emetics, analgesia and oral caffeine. Cases refractory to conservative management are treated with an autologous epidural blood patch.
Conclusions: IH is an important cause of orthostatic headache that is commonly underdiagnosed [1,2]. This leads to delays in the initiation of appropriate treatment and exposes patient to risks associated with the treatment of mimics such as meningitis or subarachnoid hemorrhage [1,2].