What are the management and evaluation recommendations for headaches that change with posture?

Management and Evaluation of Headaches That Change with Posture

Headaches that change with posture strongly suggest spontaneous intracranial hypotension (SIH) and require prompt neurological referral for diagnosis and management. 1

Key Clinical Features to Recognize

• Orthostatic headache pattern: Headache that is absent or mild when lying flat but worsens within 2 hours of becoming upright and improves by >50% within 2 hours of lying down 1
• Alternative presentation: "End of the day" or "second half of the day" headache that improves when lying flat 1
• Associated symptoms that increase suspicion of SIH:
  • Neck stiffness 1
  • Pain in cervical, thoracic, or lumbar areas 1
  • Hearing disturbances or tinnitus 1
  • Visual changes 1
  • Vertigo 1

Differential Diagnosis

1. Spontaneous intracranial hypotension (SIH): Characterized by orthostatic headache due to CSF leak 1
2. Postdural puncture headache (PDPH): Similar to SIH but occurs after neuraxial procedures 1
3. Postural tachycardia syndrome (PoTS): Diagnosed by increase in heart rate >30 beats per minute on standing 1
4. Orthostatic hypotension: Fall of >20 mmHg systolic or >10 mmHg diastolic blood pressure on standing 1
5. Cervicogenic headache: Provoked by cervical movement rather than posture 1
6. Migraine: Usually provoked by movement rather than posture 1
7. Cerebral venous thrombosis: Can occur as a complication of SIH 1, 2

Evaluation Algorithm

1. Detailed history focusing on:

   • Exact timing of headache in relation to posture 1
   • Onset characteristics (sudden vs. gradual) 1
   • Associated symptoms 1, 2
   • History of procedures, trauma, or connective tissue disorders 1

2. Physical examination:

   • Complete neurological examination 2, 3
   • Vital signs including orthostatic blood pressure and heart rate measurements 1
   • Cervical range of motion and tenderness 1, 4

3. Diagnostic testing:

   • Brain MRI with contrast: First-line imaging to look for diffuse pachymeningeal enhancement, brain sagging, and subdural collections 2, 5
   • Spine MRI: To identify the site of CSF leak 1
   • Standing test: For patients with suspected PoTS or orthostatic hypotension 1

Management Recommendations

For Suspected SIH:

1. Initial conservative measures:

   • Bed rest in supine position 1
   • Adequate hydration 1
   • Caffeine intake 6

2. If no improvement with conservative measures:

   • Epidural blood patch (EBP): First-line interventional treatment 1
   • Targeted patching if specific leak site is identified 1
   • Surgical repair for refractory cases with identified structural abnormality 1

Referral Guidelines:

• Urgent referral (within 48 hours) to a neurologist if:

  • Patient is unable to care for themselves but has help 1
  • Severe symptoms affecting daily functioning 1

• Emergency admission if:

  • Patient cannot care for themselves and lacks help 1
  • Signs of complications (subdural hematoma, cerebral venous thrombosis) 1

• Referral to specialist center if:

  • Diagnosis is in doubt 1
  • First-line treatments fail 1
  • Rapid clinical deterioration 1

Common Pitfalls to Avoid

• Missing the diagnosis: Not all orthostatic headaches present with classic symptoms; consider SIH in any new daily persistent headache with initial orthostatic quality 1, 2
• Inadequate imaging: Standard brain MRI without contrast may miss SIH findings 2, 5
• Delayed treatment: Complications like cerebral venous thrombosis can develop if SIH is left untreated 1
• Misdiagnosis as primary headache: Assuming a chronic headache is a primary disorder without considering secondary causes like SIH 2, 6
• Incomplete evaluation: Failing to perform standing tests in patients with suspected orthostatic intolerance 1

Red Flags Requiring Urgent Evaluation

• Thunderclap headache followed by orthostatic headache 1
• Neurological deficits 1, 2
• Signs of increased intracranial pressure despite positional headache (may indicate complications) 1, 2
• Headache that fails to respond to lying flat 1, 3