How do you manage headaches due to low Intracranial Pressure (ICP)?

From the Guidelines

Management of headaches due to low intracranial pressure (ICP) primarily focuses on conservative measures, followed by more invasive treatments if needed, with an epidural blood patch being a highly effective next step if initial measures fail, as supported by recent guidelines 1. Initial management includes strict bed rest, increased fluid intake (2-3 liters daily), and caffeine consumption (200-300 mg, equivalent to 2-3 cups of coffee daily) which helps constrict cerebral blood vessels and may reduce headache severity. Over-the-counter pain medications like acetaminophen or NSAIDs can provide symptomatic relief. Some key points to consider in the management of low ICP headaches include:

• The importance of identifying the underlying cause of the low ICP, such as a CSF leak, to guide treatment decisions 1.
• The use of imaging studies, such as MRI, to confirm the diagnosis and localize the source of the leak, as outlined in the ACR Appropriateness Criteria for imaging of suspected intracranial hypotension 1.
• The potential benefits and risks of epidural blood patching, including its high success rate and potential for repeat procedures if necessary 1.
• The role of surgical intervention in persistent cases where CSF leaks need to be repaired. Low ICP headaches typically worsen when upright and improve when lying down because in the upright position, reduced CSF pressure fails to provide adequate buoyancy for the brain, causing it to sag and pull on pain-sensitive structures, while lying down equalizes pressure and relieves this tension. In cases where symptoms persist after initial management, further diagnostic workup, including dynamic CT or dynamic digital subtraction myelography, may be necessary to identify the source of the CSF leak and guide targeted therapy 1.

From the Research

Management of Headaches due to Low ICP

• The management of headaches due to low Intracranial Pressure (ICP) involves both non-invasive and invasive measures 2, 3, 4.
• Non-invasive measures include bed rest, fluid resuscitation, caffeine, theophylline, and non-steroidal anti-inflammatory drugs (NSAIDs) 4.
• Invasive measures include epidural blood patch (EBP), which is considered the treatment of choice for spontaneous intracranial hypotension (SIH) 2, 3.
• EBP has been shown to be effective in reducing headache burden, intensity, and duration in patients with low CSF pressure headache 3.
• Pharmacological strategies, such as corticosteroids, may also be considered before blood patch 5.
• Empirical treatment includes administration of caffeine, corticosteroids or mineralocorticoids, epidural blood patch, and epidural saline infusion 6.

Diagnosis and Imaging

• The diagnosis of low ICP headache is typically made based on clinical presentation, including orthostatic headache, and imaging findings 2.
• Brain and spinal MRI studies, with gadolinium enhancement, may reveal diffuse pachymeningeal enhancement, "sagging" of the brain, tonsilar descent, and posterior fossa crowding 2.
• Computed tomography myelography is the diagnostic study of choice for identifying CSF leaks 2.
• Radionuclide cisternography may also be used to identify CSF leaks 2, 4.

Treatment Outcomes

• EBP has been shown to be effective in reducing headache burden, intensity, and duration in patients with low CSF pressure headache 3.
• A significant reduction in headache burden, intensity, and duration was found in a pilot study of EBP for treatment-refractory low-pressure headache 3.
• Corticosteroids have also been shown to be effective in treating headache attributed to spontaneous low CSF pressure in some cases 5.