What could be causing my severe headache and sensation of fluid leakage at the back of my neck?

Spontaneous Intracranial Hypotension (CSF Leak)

Direct Answer

Your symptoms of severe headache with a sensation of "squirting fluid" at the back of your neck are highly concerning for spontaneous intracranial hypotension (SIH) caused by a cerebrospinal fluid (CSF) leak, and you need urgent brain and spine MRI with contrast to confirm the diagnosis and locate the leak source. 1, 2, 3

Critical Diagnostic Features

The sensation of fluid "squirting" or leaking at the neck is a distinctive symptom that strongly suggests active CSF leakage through a dural tear, leaking meningeal diverticulum, or CSF-venous fistula—the three primary mechanisms causing intracranial hypotension. 2, 3 The spine represents the anatomical source in most symptomatic cases, particularly at the cervical-thoracic junction where you're experiencing this sensation. 1, 2

Key Questions to Clarify Your Diagnosis

Does your headache worsen when you stand up and improve when you lie down? This orthostatic pattern is pathognomonic for intracranial hypotension and occurs in the majority of cases. 1, 3, 4 However, approximately 20% of patients with active CSF leaks may have non-positional headaches or lose the orthostatic features over time, so the absence of this pattern does not exclude the diagnosis. 2, 4

Associated symptoms to assess:

• Nausea, vomiting, or neck stiffness 3, 4, 5
• Tinnitus, hearing changes, or "plugged ear" sensation 3, 4, 5
• Visual changes, photophobia, or horizontal double vision 3, 4, 5
• Dizziness, imbalance, or gait disturbance 3, 4
• Interscapular pain (between shoulder blades) 4, 5

Immediate Imaging Workup Required

You need TWO initial imaging studies performed urgently: 1, 3

1. Brain MRI with Gadolinium Contrast (First Priority)

This is the preferred initial imaging to confirm intracranial hypotension. 1, 3 Look for these diagnostic findings:

• Diffuse pachymeningeal (dural) enhancement - the most common finding 3, 4
• Brain sagging or descent with midbrain descent and tonsilar herniation 3, 4
• Subdural fluid collections or hematomas 3, 4
• Engorgement of venous sinuses (compensatory venodilation) 3, 4
• Pituitary gland enlargement with convex superior surface 3, 6
• Effacement of basal cisterns 3, 6

Critical pitfall: Approximately 20% of patients with active CSF leaks have completely normal brain MRI findings, so a normal scan does NOT exclude the diagnosis if clinical suspicion remains high. 2

2. Complete Spine MRI with Fluid-Sensitive Sequences

This localizes the leak source and is equally important as brain imaging. 1 The spine MRI should specifically look for:

• Epidural fluid collections at the suspected leak site 1
• Meningeal diverticula (dural outpouchings with weak points) 2, 6
• Dilated epidural venous plexus 6
• Subdural hygromas 6

MRI with fluid-sensitive sequences has equal sensitivity to CT myelography for detecting epidural collections and avoids the need for lumbar puncture, making it the preferred initial spine imaging. 1

Risk Factors to Consider

Do you have any of these predisposing conditions? 2

• Connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome) that weaken dural integrity
• History of bariatric surgery with rapid epidural fat loss
• Recent minor neck trauma (even if seemingly insignificant)

When to Suspect Alternative Diagnoses

Red flags requiring different urgent evaluation: 1, 7, 8

• Thunderclap onset (sudden, explosive headache reaching maximum intensity within seconds) - consider subarachnoid hemorrhage; needs immediate non-contrast CT head followed by lumbar puncture if CT is normal 7, 8
• Fever with neck stiffness - consider meningitis; needs immediate evaluation 1, 7
• Focal neurologic deficits (weakness, numbness, vision loss) - consider stroke or mass lesion 7, 8
• Altered consciousness or confusion - requires emergency evaluation 8

Treatment Pathway After Diagnosis

If imaging confirms intracranial hypotension: 3, 6, 4

1. Epidural blood patch (EBP) is the treatment of choice for persistent symptoms, with dramatically effective results when performed early (within weeks of symptom onset). 3, 6, 4

2. Non-targeted lumbar EBP can be performed initially (up to two attempts) if the exact leak site is unclear on imaging. 6

3. Surgical repair is reserved for clearly identified leaks that fail epidural blood patch treatment. 3

4. Conservative measures (bed rest, hydration, caffeine) may be tried first for mild cases, but EBP should not be delayed for severe or persistent symptoms. 4

Critical Complications to Monitor

Intracranial hypotension can lead to life-threatening complications: 3

• Cerebral venous thrombosis (occurs in approximately 2% of cases)
• Subdural hematomas from tearing of bridging veins
• Brain herniation in extreme cases with severe brain sagging
• Seizures from cortical irritation

Why This Diagnosis Matters for Your Outcomes

Morbidity and quality of life: Untreated CSF leaks cause debilitating orthostatic headaches that severely impair daily function, work capacity, and quality of life. 3, 4 Early diagnosis and treatment with epidural blood patch have excellent success rates and can prevent progression to complications. 6, 4

Mortality: While rare, untreated intracranial hypotension can progress to life-threatening subdural hematomas, cerebral venous thrombosis, or brain herniation. 3

The sensation of "squirting fluid" you describe is an unusual but highly specific symptom that should prompt immediate investigation—this is not a typical primary headache disorder. 4, 5