What is the best course of action for a patient with a worsening headache when laying down or bending over, suggestive of a postural component, and previously treated with metoclopramide (metoclopramide) and ketorolac (ketorolac)?

Immediate Diagnostic Workup for Suspected Spontaneous Intracranial Hypotension

This patient requires urgent MRI brain with IV contrast AND MRI complete spine to diagnose spontaneous intracranial hypotension (SIH), as headache worsening when lying down or bending over is the hallmark orthostatic pattern of CSF leak. 1, 2

Critical Diagnostic Criteria

The orthostatic headache pattern must meet specific timing requirements to confirm SIH 2:

• Absent or only mild headache upon waking or after prolonged lying flat
• Onset within 2 hours of becoming upright
• Improvement by >50% within 2 hours of lying flat
• Consistent timing pattern across episodes

Associated Symptoms That Increase Diagnostic Certainty

Actively assess for these accompanying features 1, 2:

• Nausea and vomiting (present in 28% of SIH cases)
• Neck pain or stiffness
• Tinnitus or hearing changes (11% of cases; also predicts recurrence risk)
• Photophobia
• Visual disturbances (3% of cases)
• Vertigo (8% of cases)

Mandatory Differential Diagnoses to Exclude First

Before confirming SIH, you must rule out 2:

Postural Orthostatic Tachycardia Syndrome (PoTS):

• Perform formal standing test documenting heart rate
• Diagnostic if heart rate increases >30 beats per minute on standing
• Note: Negative standing test does not exclude PoTS if clinical suspicion remains high

Orthostatic Hypotension:

• Document blood pressure drop >20 mmHg systolic and/or >10 mmHg diastolic on standing

Cervicogenic Headache:

• Headache provoked by cervical movement rather than posture
• Reduced cervical range of motion
• Associated myofascial tenderness

Imaging Protocol - Must Be Done Immediately

Order both studies simultaneously 1, 2:

Brain MRI with IV Contrast

Look for these confirmatory findings 1, 2:

• Diffuse pachymeningeal (dural) enhancement (97% of cases)
• Venous sinus engorgement
• Midbrain descent
• Pituitary enlargement (convex superior surface)
• Ventricular collapse (predicts higher recurrence risk)
• Posterior fossa crowding (predicts higher recurrence risk)

Complete Spine MRI

Identifies the leak source 1:

• Epidural fluid collections (direct evidence of CSF leak)
• CSF-venous fistula
• Dilated epidural venous plexus (indirect sign)
• Subdural hygromas (indirect sign)
• Dural enhancement (indirect sign)

Critical Pitfall to Avoid

Do NOT rely on CSF pressure measurement - CSF pressure can be normal in patients with SIH, and absence of low CSF pressure should not exclude this diagnosis 1. The diagnosis is clinical and radiographic, not manometric.

Treatment Pathway After Diagnosis Confirmation

Epidural blood patch (EBP) is first-line treatment and should be performed as soon as possible after diagnosis 1, 2:

Post-EBP Management Protocol 1:

• Monitor in recovery area with vital signs (heart rate, blood pressure, pulse oximetry) and spinal observations
• 2-24 hours bed rest and observation period
• Supine or Trendelenburg position for non-targeted patches
• Supine with head elevated as comfortable for targeted patches
• Thromboprophylaxis during immobilization per institutional VTE policy

Post-Discharge Instructions 1:

• Lie flat as much as possible for 1-3 days
• Minimize for 4-6 weeks: bending, straining, stretching, twisting, closed-mouth coughing, sneezing, heavy lifting, strenuous exercise, constipation

Emergency Return Precautions 1

Instruct patient to seek urgent medical attention for:

• New-onset severe back or leg pain
• Lower limb motor weakness or sensory disturbance
• Urinary or fecal incontinence
• Urinary retention
• Perineal sensory disturbance
• Nausea and vomiting
• Fever

Recognizing Rebound Headache vs. Treatment Failure

Rebound headaches occur in 25% of patients 1-2 days post-EBP 1:

Characteristic Features of Rebound Headache 1:

• Reversal of orthostatic pattern: relief upright, worse lying down
• Headache location change: from occipital to frontal/periorbital/retroorbital
• Associated symptoms: nausea, emesis, blurry vision
• Self-limited: usually resolves without intervention

Management of Rebound Headache 1:

• Conservative management first - do NOT repeat imaging or EBP
• Acetazolamide to lower CSF production
• CSF drainage via lumbar puncture or lumbar drain only for severe refractory cases

High-Risk Features for Recurrence

Identify patients at higher risk requiring closer follow-up 2:

• Ventricular collapse on brain MRI
• Posterior fossa crowding
• Longer delay between symptom onset and treatment
• Persistent tinnitus

Life-Threatening Complication to Monitor

Cerebral venous thrombosis (CVT) complicates SIH in rare cases 1:

• Occurs in 86% of documented SIH-CVT cases, often initially unrecognized
• Order CT or MR venography for any sudden change in headache pattern or new neurological findings
• EBP should be prioritized as initial treatment even with CVT present
• Consider anticoagulation balancing risks and benefits

Why Previous Treatment Failed

The patient received metoclopramide and ketorolac, which are migraine-specific treatments that do not address CSF leak 1, 3. While metoclopramide is effective for migraine (though with slower onset than other agents) 4, 5, and ketorolac shows good efficacy for acute migraine 3, 6, 7, neither treats the underlying pathophysiology of SIH. The orthostatic pattern (worse lying down/bending) distinguishes this from migraine, where headache is typically provoked by movement rather than posture 2.