From the Guidelines
The primary treatment for orthostatic headaches is a non-targeted epidural blood patch (EBP), which should be performed as early as possible, as recommended by the most recent multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension 1. The treatment approach for orthostatic headaches involves several key steps:
- First-line imaging should be MRI of the brain with contrast and the whole spine to confirm the diagnosis and identify potential sources of cerebrospinal fluid (CSF) leakage.
- Non-targeted epidural blood patch (EBP) is the first-line treatment and should be performed as soon as possible to directly address the underlying cause of the headache, which is often a CSF leak.
- The EBP procedure involves injecting 15-20 mL of autologous blood into the epidural space to seal the leak site and increase CSF pressure.
- Patients should be advised to avoid activities that increase intracranial pressure, such as heavy lifting or straining, during treatment and for several weeks afterward to prevent recurrence.
- Conservative management, including hydration and caffeine intake, may be considered as an adjunct to EBP, but the primary treatment should focus on addressing the underlying CSF leak.
- The diagnosis and treatment of orthostatic headaches can be challenging, and a comprehensive diagnostic workup, including imaging and potentially invasive procedures like myelography, may be necessary to confirm the diagnosis and guide treatment 1.
From the FDA Drug Label
Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations
The treatment for orthostatic (postural) headaches is midodrine, which is used to treat symptomatic orthostatic hypotension (OH), a condition that can cause headaches. However, it is essential to note that midodrine should only be used in patients whose lives are considerably impaired despite standard clinical care. 2
From the Research
Treatment for Orthostatic (Postural) Headaches
The treatment for orthostatic (postural) headaches can be approached through various methods, including pharmacological and non-pharmacological interventions.
- Pharmacological Interventions:
- Fludrocortisone is considered a first- or second-line pharmacological therapy for orthostatic hypotension, which can be associated with orthostatic headaches 3.
- Antidepressants have been found to be effective in treating persistent orthostatic headache without intracranial hypotension, with some patients experiencing significant improvement or becoming pain-free 4.
- Non-Pharmacological Interventions:
- Increasing fluid and sodium chloride intake can help improve orthostatic tolerance 5.
- Drinking water has been shown to elicit a rapid pressor response in patients with autonomic failure and can be used to treat orthostatic and postprandial hypotension 6.
- Physical counter-maneuvers such as leg crossing, leg muscle pumping/contractions, and bending forward can improve orthostatic hypotension 7.
- Eating smaller, more frequent meals and avoiding large meals can help manage orthostatic symptoms 7.
- Sleeping with the head tilted up, in combination with other treatments, may also be beneficial 7.
Considerations for Treatment
It's essential to tailor the treatment approach to the individual patient, considering their specific condition, symptoms, and response to different interventions. While some non-pharmacological interventions may not result in clinically meaningful changes for all patients, they can still be effective as part of a comprehensive treatment plan 7.