New Onset Pressure Headaches × 1 Month
For a patient with new onset pressure headaches lasting one month, you must immediately obtain MRI brain with contrast and MRI whole spine to rule out spontaneous intracranial hypotension (SIH) or other secondary causes, as the one-month duration and "pressure" quality warrant urgent neuroimaging to exclude potentially serious pathology. 1
Immediate Diagnostic Evaluation
Critical Red Flags to Assess
- Orthostatic component: Ask specifically if headache worsens when standing/sitting and improves when lying flat—this is the cardinal feature of SIH 2
- Aggravating factors: Determine if headache worsens with Valsalva maneuvers, coughing, bending, or exertion—suggests elevated intracranial pressure 2
- Associated symptoms: Screen for nausea, vomiting, visual changes (blurring, transient visual obscurations), tinnitus, diplopia, or cognitive changes 2
- Neurological examination: Perform fundoscopy to assess for papilledema (indicates intracranial hypertension), check for sixth nerve palsy bilaterally, and complete cranial nerve and motor/sensory examination 2
- Age consideration: Patients over 50 years with new headache have up to 15% risk of serious pathology including temporal arteritis, stroke, or neoplasm 3
Mandatory Imaging Protocol
Order MRI brain with gadolinium contrast AND MRI whole spine immediately 2, 1. This combination is essential because:
- For SIH detection: Look for diffuse smooth pachymeningeal enhancement, brain sagging, subdural collections/hygromas, and spinal longitudinal epidural collections (SLEC) 2
- For intracranial hypertension: Assess for empty/partially empty sella, optic nerve sheath enlargement, posterior globe flattening, optic nerve tortuosity, and transverse sinus stenosis 2
- For other pathology: Rule out mass lesions, vascular malformations, or Chiari malformation 4, 5
The pre-test probability of finding significant intracranial abnormality in chronic headache with normal neurological exam is approximately 0.9%, but this increases substantially with specific clinical features 5.
Management Based on Imaging Results
If MRI Shows Signs of Spontaneous Intracranial Hypotension
Immediate management includes 2, 1:
- Strict bed rest: Lie flat in supine position for 1-3 days 2
- Aggressive hydration: Maintain high fluid intake continuously 6
- Caffeine supplementation: Can temporarily increase CSF production 2
- Refer urgently to neurosurgery/specialized center: Within 2 weeks if conservative measures fail 2, 1
- Consider epidural blood patch (EBP): Non-targeted high-volume EBP is first-line interventional treatment if conservative measures fail 2, 1
Critical pitfall: If patient develops new headache pattern after EBP (frontal/periorbital location, worse lying down, better upright), this represents rebound intracranial hypertension—do NOT repeat imaging or additional patches as this is self-limited and resolves in 1-2 weeks 2.
If MRI Shows Signs of Intracranial Hypertension
Measure blood pressure first to exclude hypertensive emergency 1. Then:
- Perform lumbar puncture: Measure opening pressure (>25 cm H2O confirms elevated ICP) and this procedure itself is therapeutic 2
- Initiate acetazolamide: Start 250-500 mg twice daily, titrate up to maximum 4 g/day as tolerated 2
- Weight loss counseling: If patient is overweight, this is the most important long-term intervention 2
- Ophthalmology referral: Urgent evaluation for papilledema and visual field testing 2
Important caveat: Serial lumbar punctures are NOT recommended for ongoing management despite temporary symptom relief 2.
If MRI is Normal
With normal imaging, the differential includes:
- Tension-type headache (most common—38% prevalence) 4
- New daily persistent headache 4
- Chronic migraine (if ≥15 headache days/month for >3 months with migraine features on ≥8 days) 7, 4
- Occult CSF leak: In high clinical suspicion cases with normal MRI, consider CT myelography or digital subtraction myelography in lateral decubitus position to detect CSF-venous fistula 2
Symptomatic Management During Workup
Acute Pain Control
- First-line: Acetaminophen and/or NSAIDs (ibuprofen, naproxen) 1, 6, 4
- NSAIDs have dual benefit: Provide analgesia AND may reduce intracranial pressure 2, 6
- Gastric protection: Prescribe proton pump inhibitor if using NSAIDs regularly 2, 6
- Avoid opioids: Do not prescribe for headache management except as very short-term bridge therapy 2, 6
Critical Medication Overuse Warning
Counsel patient immediately about medication overuse headache thresholds 2, 7:
- Simple analgesics (acetaminophen, NSAIDs): Do not exceed 15 days/month
- Combination analgesics, triptans, or opioids: Do not exceed 10 days/month
- Exceeding these thresholds for >3 months causes medication overuse headache, which perpetuates the problem 2, 7
Medications to AVOID
Do not prescribe the following as they can worsen orthostatic symptoms if SIH is present 6:
- Topiramate (lowers CSF pressure)
- Indomethacin (lowers CSF pressure)
- Beta-blockers (worsen orthostasis)
- Candesartan (worsen orthostasis)
When to Consider Preventive Therapy
If headaches persist after excluding secondary causes and occur frequently with functional impairment 7:
- CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab): First-line preventive option, monthly subcutaneous injection, reduces migraine days by 2-4.8 days/month 7
- Topiramate: Second-line option if CGRP antibodies unavailable, start 25 mg daily and titrate to 100-200 mg daily, but avoid if any concern for low CSF pressure 7
- Allow 2-3 months to assess preventive medication efficacy before abandoning therapy 7