Clinical Challenge: What Do These Changes in Headache Pattern Signify?

There are a few important points in this case that are important to keep in mind. First, when a patient with a primary headache has a change in headache pattern, it is vital to make sure that there is not another cause of their headaches. In this case, even though the character of her headaches is similar to her usual migraine headaches, the patient’s usual headaches have now progressed from weekly to daily over a short period of time. In addition, the headaches are related to position, as they worsen over the course of the day. It is important to make sure that there is not a new process or secondary headache that may be causing the patient’s new headaches or exacerbating her migraines. The mnemonic SNOOP (Systemic symptoms/signs or systemic disease; Neurologic symptoms, Onset, Older, Pattern change from previous headache history) is frequently used to detect possible red flags during a headache history and physical examination that may point to a secondary cause of headaches.

For this patient, the positional component of her headaches point to a low pressure headache or a dural tear that could be causing a cerebrospinal fluid (CSF) leak. She notes that her headaches started during a yoga class, during which time stretching of her neck may have caused the tear; however, frequently there is not a causative factor linked with a CSF leak. Although not always present, worsening of headache with upright position or improvement of headaches when lying flat points toward a low-pressure headache. The usual work up includes a myelogram or MRI of the brain and cervical spine with contrast to find the area of the leak, although these may also be negative. A lumbar puncture with low opening pressures may also be helpful in diagnosing the cause of the headache. The typical treatment is an epidural blood patch or the addition of an abortive medication with caffeine that helps to increase the intracranial pressure. Amitriptyline as a preventive can also be helpful.

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In this case, the patient was given a blood patch, resulting in significant improvement in her daily headaches. Even in patients with a long history of migraine, it is important to take a thorough history and perform a thorough physical examination at each visit to make sure that there are no other processes that may be causing or worsening a primary headache. This is especially true if there is a change in the pattern or character of the headaches.

Intracranial hypotension typically can result from a CSF leak, either spontaneously or from trauma, as well as occasionally after surgery. This is only now beginning to be recognized as an important — and sometimes underdiagnosed — cause of headaches. When CSF begins to leak, it can cause loss of CSF volume. This can lead to subdural fluid collection and an increase in intracranial venous blood, pachymeningeal thickening, enlarged pituitary, and engorgement of cerebral venous sinuses on MRI. It can also cause descent of the cerebellar tonsils and brainstem visible on MRI. An epidural blood patch can be very effective when more conservative treatments have failed.

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1. Mokri B. Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks. Headache. 2013;53(7):1034-1053.

2. Dodick D. Diagnosing headache: clinical clues and clinical rules. Adv Stud Med. 2003;3(2):87-92.

This article originally appeared on Neurology Advisor