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What are Positional Headaches?

Also known as orthostatic or postural headaches, positional headaches occur when a sudden change in positioning such as quickly sitting or standing happens and is  relieved by lying down for 20-30 minutes. They can last for anywhere between 5 minutes and 48 hours, and are not commonly associated with many symptoms other than pain. 

Signs and symptoms: 

  • Pain (severe, throbbing, pulsating, aching, stabbing)
  • Worse throughout the day
  • Most commonly back of the head, but can be on the side or at the front in rare cases
  • Hearing changes or double vision
  • Dizziness 
  • Back or chest pain

Symptoms are commonly worsened by

  • coughing or sneezing
  • strenuous exercises
  • sexual activities
  • bending over, lifting, reaching
  • straining during a bowel movement

Causes

Spontaneous intracranial hypotension is a low pressure headache caused by leaking of CSF, meaning that there is reduced fluid cushioning the spinal and brain tissue. The balance in fluid volume is delicate and even small leaks are enough to greatly disrupt the pressure, resulting in the symptoms listed above.  Often this will occur after a surgery or obvious trauma to the head and neck, but sometimes the event may be less obvious such as a sneeze, a cough or an unrecognised event. People who have a weaker connective tissue composition or have hyperflexibility of their joints tend to be more susceptible and prone to this kind of injury.

Positional headaches may also be caused by structural conditions or problems with the intervertebral disc, connective tissues, nerves, blood vessels, facet joints, muscles, contributing to the headache.

Management

Recommended management is normally medical, with the first suggested line of treatment being an epidural blood patch. Blood is drawn from the patient’s arm and then injected into the epidural space of the patient’s lower spine using imaging to guide. The blood clot that forms helps to block the tear in the dura, and thus stop the leak, allowing the pressure to equalise. There may be subsequent back pain, but most patients experience immediate symptomatic relief from all headache related symptoms after the procedure. Patients may have to have multiple blood patches if leaking re-occurs. 

For more mild cases, patients may find symptomatic relief from the following: getting bed rest or lying flat, hydrating or IV therapy, avoiding strenuous and straining activities, drinking caffeine, eating healthily, practicing medication or using an abdominal binder. However, it is rare that any of these would be successful long term treatments. 

References:

https://www.medicalnewstoday.com/articles/326965

https://americanmigrainefoundation.org/resource-library/know-low-pressure-headaches/

https://www.hopkinsmedicine.org/health/conditions-and-diseases/headache/low-csf-headache