What could be causing my headaches that resolve when I lay on my left side?

Differential Diagnosis: Headache Resolving with Left Lateral Positioning

Your headache that resolves when lying on your left side most likely represents spontaneous intracranial hypotension (SIH), which requires urgent neurological evaluation within 2-4 weeks if you can care for yourself, or within 48 hours if you cannot. 1, 2

Primary Diagnosis: Spontaneous Intracranial Hypotension

SIH should be your leading diagnosis when headache improves dramatically with specific positioning. 1, 2 The characteristic orthostatic pattern includes:

• Absent or minimal pain (1-3/10 severity) upon waking or after prolonged lying flat 1, 2
• Headache onset within 2 hours of becoming upright 1, 2
• Greater than 50% improvement in severity within 2 hours of lying flat 1, 2
• Consistent timing of onset and offset with positional changes 1, 2

The fact that your headache specifically resolves with left lateral positioning (rather than just any supine position) is consistent with SIH, as patients often find relief in specific positions that optimize CSF dynamics. 1

Associated Symptoms That Increase Diagnostic Certainty

Look for these accompanying features that strengthen the diagnosis of SIH:

• Nausea and vomiting 1, 2, 3
• Neck pain or stiffness 3
• Hearing changes (muffled hearing, tinnitus) 2, 3
• Visual disturbances 2
• Dizziness 2
• Photophobia 3

Critical Differential Diagnoses to Exclude

Orthostatic Hypotension

This is distinguished by documented blood pressure changes, not just headache pattern. 1, 2, 3 You need:

• Blood pressure drop ≥20 mmHg systolic OR ≥10 mmHg diastolic upon standing 1, 2, 3
• Formal standing test with hemodynamic monitoring at 1,3,5, and 10 minutes 2, 3

Postural Tachycardia Syndrome (PoTS)

PoTS presents with orthostatic intolerance but is characterized by heart rate changes. 1, 2, 3 Diagnostic criteria include:

• Heart rate increase >30 beats per minute within 10 minutes of standing 1, 2, 3
• Symptoms of orthostatic intolerance (lightheadedness, palpitations, tremulousness) 2
• Note: A negative standing test does NOT exclude PoTS if clinical suspicion remains high 1, 3

Cervicogenic Headache

This is provoked by neck movement, NOT posture. 1, 2 Key distinguishing features:

• Headache triggered by cervical movement rather than positional changes 1, 2
• Reduced cervical range of motion 1, 2
• Associated myofascial tenderness on palpation 1, 2

Migraine

Migraine is provoked by movement, not posture. 1, 2 Distinguishing characteristics:

• Aggravation by routine physical activity (walking, climbing stairs) 1
• Migrainous features: unilateral, pulsating, moderate-to-severe intensity 1
• Photophobia and phonophobia 1
• Nausea and/or vomiting 1

Diagnostic Workup Algorithm

Step 1: Detailed Orthostatic History

Document the precise pattern: 2, 3

• Severity when lying flat versus standing (use 0-10 scale) 1
• Time to onset after standing (should be <2 hours for SIH) 1, 2
• Time to improvement after lying flat (should show >50% improvement within 2 hours) 1, 2
• Consistency of this pattern across multiple episodes 1, 2

Step 2: Physical Examination

Perform a focused neurological assessment: 2, 4

• Complete neurological examination looking for focal deficits 2, 4, 5
• Fundoscopy to assess for papilledema 2, 5
• Cervical spine range of motion and palpation for tenderness 2
• Vital signs including orthostatic measurements 2

Step 3: Formal Standing Test

If orthostatic hypotension or PoTS is suspected: 2, 3

• Measure blood pressure and heart rate supine 2, 3
• Repeat measurements at 1,3,5, and 10 minutes of standing 2, 3

Step 4: Neuroimaging

For suspected SIH based on orthostatic headache pattern: 2, 3

• Order MRI brain with IV contrast AND MRI complete spine immediately 3
• Look for confirmatory findings: diffuse pachymeningeal enhancement, venous sinus engorgement, midbrain descent, pituitary enlargement, ventricular collapse 3

Red Flags Requiring Urgent Evaluation

Seek immediate evaluation if you experience: 4, 5

• Worst headache of your life with sudden onset 4, 5
• Neurological deficits (diplopia, dysarthria, numbness, weakness) 4, 5
• Altered mental status or fever 4, 5
• Headache after head or neck trauma 4, 5
• Focal neurologic signs or papilledema 5

Referral Pathway

Refer to neurology based on functional status: 1

• Within 2-4 weeks if you can care for yourself 1
• Within 48 hours if you cannot care for yourself but have help 1
• Emergency admission if you cannot care for yourself and lack help 1

Refer to a specialist neuroscience center if: 1

• Diagnosis remains uncertain 1
• First-line treatments fail 1
• Rapid clinical deterioration occurs 1
• Serious complications develop (subdural hematoma with mass effect) 1

Common Pitfalls to Avoid

Do not dismiss positional headaches as simple migraine or tension-type headache. 1, 2 The orthostatic pattern is highly specific for intracranial hypotension and requires investigation. 1, 2

Do not assume a negative standing test excludes PoTS. 1, 3 If clinical suspicion remains high, consider additional autonomic testing. 1

Do not delay neuroimaging in patients with consistent orthostatic headache patterns. 3 Early diagnosis of SIH allows for timely treatment and prevents complications. 1