04.01 Neuro
04.01 Neuro [PDF link]: Headaches – Migraines, Trigeminal autonomic cephalgia, including cluster headaches, SUNCT, SUNA, Trigeminal neuralgia, Tension headaches (aka tension-type headache), Medication overuse headaches, Temporal arteritis / Giant cell arteritis, Other causes of headache, Headache red flags
Spontaneous intracranial hypotension
D: clinical syndrome resulting from reduced CSF
R: recent spinal procedure or injury (eg lumbar puncture)
A: (1) dural tears (eg lumbar puncture, trauma), (2) meningeal diverticula, (3) CSF-venous fistula malformation
A/P: leakage of CSF causes low CSF pressure
Postural headaches specifically develop due to reduction in the “cushion” around the brain – the brain “sags” and pulls on pain-sensitive intracranial and meningeal structures causing headache. In the upright position, there is increased traction.
S/smx
Postural headache – worse on being upright, improving on lying down.
No specific single pattern of headache has been described
Headaches are chronic in nature
May be a/w nausea, vomiting, neck pain or stiffness, tinnitus and dizziness.
Ix: MRI head and whole spine (brain MRI may show sagging of brain, and whole spine MRI may identify site of CSF leak), LP to demonstrate low opening pressures (but LP itself can worsen headaches, so used more if MRI is inconclusive)
Mx:
Conservative (could be trialled if headache <2w): bedrest, caffeine (200-300 mg BDS/TDS), oral rehydration, high salt intake, analgesia
Lumbar epidural blood patch (10-20mL of pt’s own blood is infused into the epidural space).
More invasive options include spinal surgery
Prognosis: generally good. ~10% recurrence.
Interesting article – Owais SB, Kianirad Y. Spontaneous Intracranial Hypotension. N Engl J Med 2025;393:487–487. https://doi.org/10.1056/NEJMicm2502293.
P.S. Not putting this in the book because this is not high yield. Just interesting.
