Symptoms of CSF Leak
The hallmark symptom of a CSF leak is an orthostatic (positional) headache that worsens when upright and improves when lying flat, occurring in approximately 83% of patients. 1
Primary Symptoms
Headache Characteristics
- Postural/orthostatic headache is the defining feature, present in 83% of cases, characterized by worsening when standing or sitting and improvement when supine 1
- The headache may initially be non-positional or lose its orthostatic features over time, and can evolve into persistent chronic daily headache 2, 3
- Onset can be gradual, subacute, or thunderclap in nature 3
- Non-postural headache occurs in 14% of patients 1
Associated Neurological Symptoms
- Nausea and/or vomiting occur in 28-77% of patients 1
- Neck pain or stiffness (nuchal rigidity) is present in 35% of cases 1
- Photophobia (light sensitivity) is commonly reported 1
- Auditory disturbances including tinnitus and changes in hearing occur in 11% of patients 1
- Visual disturbances including diplopia (double vision) occur in 3-11% of cases 1, 3
Secondary Symptoms
Vestibular and Motor Symptoms
- Disequilibrium or vertigo occurs in 8% of patients 1, 3
- Sensory changes are present in 11% of cases 1
- Altered mental status occurs in 8% of patients 1
- Rarely, plegia/paresis (weakness or paralysis) may occur in 3% 1
Other Manifestations
- Interscapular pain (pain between the shoulder blades) is a recognized symptom 3
- Seizures may occur in 8% of cases, particularly as a complication of cerebral venous thrombosis 1
Important Clinical Pitfalls
The orthostatic nature of the headache may not always be present or may evolve over time, leading to delayed or missed diagnosis 2, 3. The condition is highly underdiagnosed and misdiagnosed, with symptoms often attributed to more common headache etiologies 1.
A history of minor antecedent trauma may be present but is not required for spontaneous CSF leaks 3. Risk factors include spinal osteophytes, collagen vascular disease with weakened dura, and history of bariatric surgery 1.
Warning Signs of Complications
- Sudden change in headache pattern may indicate cerebral venous thrombosis, which occurs in approximately 2% of SIH cases but can be life-threatening 4, 5
- New neurological deficits including motor weakness, sensory disturbances, or cranial nerve palsies warrant urgent evaluation 1, 4
- Seizures or altered consciousness may indicate intracranial hemorrhage or venous thrombosis complications 1