Know about Low CSF Volume Headache


Low CSF (cerebrospinal fluid) volume headache is a type of secondary NDPH (New Daily Persistent Headache). Other secondary NDPH are high CSF pressure headache, post traumatic headache, headache due to chronic meningitis etc.


What are the symptoms of low CSF volume headache?


The head pain in low CSF volume headache is generally positional (depends on the body position or posture) and begins upon standing upright or in sitting position and tend to resolve if reclined or on lying down. The head pain of low CSF volume headache is commonly dull aching in nature, although sometimes it may be throbbing type of pain and localized occipitofrontal (from and back of the head) area. The head pain of low CSF volume headache improves/resolve upon reclining within few minutes but may return again on resuming upright position within minutes to an hour. The typical clinical presentation of low CSF volume headache patient is history of absence of head pain on waking in the morning but worsen during day time and the next day same may be repeated. As the time passes the postural nature of low CSF volume headache becomes less evident.


What are the causes of low CSF volume headache?


The main cause of low CSF volume headache of persistent nature is leakage of CSF from lumbar puncture (LP) site. If low CSF volume headache is due to CSF leakage from lumber puncture site the headache generally appear within 48 hours of the procedure (LP), but may appear even after 12 days. The incidence of low CSF volume headache after LP is estimated to be between 10%-30%.


Other causes of CSF leakage include a vigorous Valsalva maneuver (it is blowing of nose forcefully after closing nostrils and mouth, can occur during lifting heavy objects, straining, coughing, clearing the eustachian tubes in an airplane, or multiple orgasms) or epidural injection. There may also be spontaneous leakage of CSF. Sometimes several years may pass after events such as LP or epidural injection before the diagnosis of low CSF volume headache is made.


The symptoms of low CSF volume headache are due to low volume of CSF, rather than due to low CSF pressure, because sometimes low CSF volume headache may be present when CSF pressure is high but there is leakage of CSF.


What investigations are done in low CSF volume headache?


MRI with gadolinium can identify the source of CSF leakage is preferred. The source of CSF leakage may also be identified by CT scan, spinal MRI etc. If the source of CSF leakage can not be identified early emptying of 111In-DTPA tracer into the bladder suggests leakage of CSF.


How low CSF volume headache is treated?


Treatment is started with bed rest. Caffeine intravenously at the dose of 500 mg in 500 ml saline administered over 2 hours is also very effective in persistent head pain. An ECG should be done to check if any arrhythmia is present before giving caffeine. It is advisable to try at least 2 administration of caffeine (it is a safe drug) before going for additional investigations as caffeine may be curative treatment in many patients with low CSF volume headache and saves many patients from further investigations and trouble. If the source of leakage is identified an autologous blood patch is usually curative, even in case of headache due to CSF leakage from lumbar puncture and the site of LP is taken as the source of CSF leakage.


Some patients with intractable head pain due to low CSF volume headache, theophylline orally may be helpful although it is less effective and slower than caffeine.

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