What’s the Most Likely Cause of This Man’s Severe Headaches?

What is the Most Possible Reason for This Man’s Extreme Complications?

A 35-year-old man involves clinic for analysis of recent, extreme complications. He experiences that these began 3 days in the past. His headache is worse when he stands, and resolves when he lies down. Valsalva maneuver makes the headache a lot worse. The complications are current within the occipital area. He has additionally observed the onset of tinnitus. A bodily examination reveals that his blood strain is 110/70 mm Hg, his pulse is 60 beats per minute, and his temperature is 36.4° C. His standing BP is 105/60 mm Hg and standing pulse is 66 bpm. Each his neurologic examination and noncontrast head CT scan are regular.

Which of the next is the almost definitely analysis?

A) Subarachnoid hemorrhage

B) POTS (Postural orthostatic tachycardia syndrome)

C) Hypnic headache

D) Spontaneous intracranial hypotension (SIH)

E) Acoustic neuroma

The almost definitely trigger for this affected person’s complications given his set of signs is spontaneous intracranial hypotension. Orthostatic complications are frequent with POTS, however the absence of tachycardia with standing makes this analysis unlikely.

Dr Douglas S. Paauw

Spontaneous intracranial hypotension has signs that we’re all acquainted with within the post-lumbar puncture affected person. In sufferers with post-LP headache, the positional nature makes it straightforward to diagnose. Sufferers who’ve had a lumbar puncture have a transparent motive they’ve a cerebrospinal fluid (CSF) leak, resulting in intracranial hypotension. These with SIH don’t.

Associated Analysis

Schievink summarized a variety of helpful data in a evaluate of sufferers with spontaneous intracranial hypotension.1 The incidence is about 5/100,000, with the most typical age round 40 years outdated. The most typical symptom is orthostatic headache. The headache normally happens inside quarter-hour upon standing, and lots of sufferers have the onset of headache quickly upon standing.

Normally the headache improves with mendacity down, and it’s usually introduced on with Valsalva maneuver. Many sufferers report complications which might be worse within the second half of the day.

Orthostatic headache happens in nearly all sufferers with spontaneous intracranial hypotension, however in a single sequence it occurred solely in 77% of sufferers with SIH.2 The sufferers who didn’t have typical complications usually tend to have auditory signs comparable to tinnitus and muffled listening to.3

Once you suspect SIH, acceptable workup is to start out with mind MR imaging with distinction. Krantz and colleagues discovered dural enhancement was current in 83% of circumstances of SIH, venous distention check in 75%, and mind sagging in 61%.4

About 10% of sufferers with SIH have regular mind imaging, so if the medical options strongly counsel the analysis, shifting on to spinal imaging with CT myelography or spinal MR are acceptable subsequent steps.5

The causes of SIH are meningeal diverticula (normally within the thoracic or higher lumbar areas), ventral dural tears (normally from osteophytes), and cerebrospinal fluid–venous fistulas. Remedy of SIH has historically included a conservative method of mattress relaxation, oral hydration, and caffeine. The effectiveness of that is unknown, and, in a single small sequence, 61% had headache signs at 6 months.6

Epidural blood patches are seemingly extra quickly efficient than conservative remedy. In a single examine evaluating the 2 remedies, Chung and colleagues discovered that 77% of the sufferers who acquired an epidural blood patch had full headache aid at 4 weeks, in contrast with 40% of those that acquired conservative measures (P <.05>7

Scientific Pearls

  • Strongly think about SIH in sufferers with positional headache.

  • Mind MR must be the primary diagnostic check.

Paauw is professor of drugs within the division of common inside drugs on the College of Washington, Seattle, and serves as Third-year medical scholar clerkship director on the College of Washington. He’s a member of the editorial advisory board of Inside Drugs Information. Paauw has no conflicts to reveal. Contact him at [email protected]

This story initially appeared on MDedge.com, a part of the Medscape Skilled Community.

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