What are the potential causes and recommended treatments for a patient experiencing a severe headache with ear pain, sinus pressure, and a sensation of fluid squirting on the back of the head, particularly concerning for a potential cerebrospinal fluid (CSF) leak?

Suspected Spontaneous Intracranial Hypotension (CSF Leak)

You likely have spontaneous intracranial hypotension from a cerebrospinal fluid leak, and you need urgent neuroimaging with MRI brain with contrast and complete spine MRI to confirm the diagnosis and locate the leak source. 1

Why This Is Most Likely a CSF Leak

Your symptom constellation—severe positional headache, ear pain, sinus pressure, and the unusual "squirting fluid sensation" at the back of your head—strongly suggests spontaneous intracranial hypotension (SIH) from a spinal CSF leak. 2, 1

• The orthostatic nature of your headache (worse when upright, better lying down with head propped on pillows) is pathognomonic for intracranial hypotension 1
• Ear pain and changes in hearing are well-documented symptoms of SIH, occurring due to compensatory venodilation and downward traction on cranial nerves 2
• The "squirting fluid sensation" may represent your perception of CSF pressure changes or compensatory vascular pulsations 2

Critical Diagnostic Pitfall to Avoid

Do not dismiss this diagnosis if a lumbar puncture shows normal CSF opening pressure—clinical presentation and imaging findings are more important than measured CSF pressure. 1, 3 Many patients with confirmed SIH have normal CSF pressure measurements. 2

What's Actually Happening in Your Body

The pathophysiology involves two mechanisms: 2

• Compensatory venodilation and blood volume expansion as your body attempts to maintain stable intracranial volume despite decreased CSF
• Downward traction on your meninges, nerves, and brain parenchyma as your brain loses buoyancy and begins to sag

The spine is the source of most symptomatic CSF leaks because spinal hydrostatic pressure is positive relative to atmosphere in the upright position, while intracranial pressure is slightly negative. 2, 1

Immediate Imaging Required

First-line imaging consists of MRI brain with IV contrast AND MRI complete spine to both confirm intracranial hypotension features and localize the spinal leak source. 1, 3

Key imaging findings to look for include: 2

• Diffuse pachymeningeal (dural) enhancement
• Engorgement of venous sinuses
• Downward displacement of the brain (midbrain descent, tonsillar descent)
• Subdural hygroma or hematoma
• Epidural fluid collections along the spine
• Dilated epidural venous plexus

Why "Sinus Headache" Is a Misleading Diagnosis

Most patients who believe they have "sinus headache" actually have migraine. 4 However, your specific symptom pattern—particularly the positional nature and fluid sensation—points away from both migraine and true rhinosinusitis toward SIH. 5, 4

Differential Diagnoses to Briefly Consider

Before confirming SIH, briefly evaluate for: 1

• Postural orthostatic tachycardia syndrome (PoTS)
• Orthostatic hypotension
• Migraine with atypical features

These can be quickly assessed through orthostatic vital signs and headache characteristics, but your symptom pattern strongly favors SIH.

Risk Factors You May Have

Consider whether you have any predisposing conditions: 1

• Collagen vascular disease (joint hypermobility, easy bruising, history of retinal detachment) 6
• History of bariatric surgery
• Spinal osteophytes
• Previous history of idiopathic intracranial hypertension

Treatment Algorithm Once Diagnosed

Early epidural blood patch (EBP) is first-line treatment and should be performed as soon as possible after diagnosis. 1, 3

Initial conservative management (if symptoms <72 hours): 3

• Bed rest in supine or Trendelenburg position for 2-24 hours
• Aggressive hydration
• Paracetamol and/or NSAIDs for pain
• Thromboprophylaxis during immobilization

If symptoms persist beyond 72 hours or are severe: 3

• Non-targeted epidural blood patch initially
• Myelography reserved for cases that fail to respond
• Targeted treatment (percutaneous fibrin glue, surgical repair) for identified leak sites 2

Life-Threatening Complication to Watch For

Cerebral venous thrombosis (CVT) occurs in approximately 2% of SIH cases and is life-threatening. 1, 3 Seek immediate emergency care if you develop:

• Sudden change in headache pattern
• New neurological symptoms (weakness, numbness, vision changes)
• Seizures
• Altered mental status

CT or MR venography should be performed urgently if CVT is suspected. 1, 3

Post-Treatment Restrictions

After EBP, you must: 3

• Lie flat as much as possible for 1-3 days
• Minimize bending, straining, stretching, twisting, coughing, heavy lifting, and strenuous exercise for 4-6 weeks
• Not drive yourself home
• Avoid constipation

When to Return to Emergency Department

Seek immediate medical attention for: 3

• New severe back or leg pain
• Lower limb motor weakness or sensory disturbance
• Urinary or fecal incontinence
• Nausea, vomiting, or fever
• Sudden change in headache pattern

Success Rate and Prognosis

Surgical treatment for spontaneous spinal CSF leaks has excellent outcomes, with complete relief of headaches in all patients in surgical series, with no recurrence during extended follow-up. 7 Most patients respond well to epidural blood patches, though some require multiple patches or surgical intervention. 6, 7