Headache Due to Low Pressure – SIH Headache

The brain is supported and cushioned from its surroundings by Cerebrospinal fluid which is constantly made and absorbed to maintain the spinal fluid volume and pressure normal. A decrease in spinal fluid leads to (Spontaneous Intracranial Hypotension) SIH Headache.

Location of pain

Headache is typically felt in the back of the head and neck but is also reported by many patients in the forehead and one side of head.

Duration of pain

The pain gradually improves upon lying down and might vanish within half an hour.

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Character of Pain

Aching, Pulsating, Stabbing, or Throbbing pain with no specific character.

Symptoms

  • Photophobia and phonophobia
  • Tinnitus
  • Nausea
  • Dizziness
  • Vomiting
  • Diplopia
  • Neck pain
  • Disrupted cognitive function
  • Loss of consciousness
  • Coma
  • Tremors
  • Parkinsonism like symptoms

The intensity of pain ranges from dull to severe. The pain usually increases upon sitting up or standing. Also increases upon straining like with Cough, Sneeze, Sexual Intercourse and Excercise.

Causes

  • The Cerebrospinal fluid surrounds the brain and spinal cord and acts as a cushion against trauma. Any change in volume or pressure of Cerebrospinal Fluid can cause a headache. SIH Headache is spontaneous in onset and is caused due to low pressure exerted by the cerebrospinal fluid on the brain and spinal cord.
  • Spinal tap: The cerebrospinal fluid leaks through the small puncture hole made for a spinal tap. Constant leakage of fluid can decrease the pressure around the brain resulting in SIH Headache also known as Spinal Headache.
  • Decreased pressure can cause sagging of the brain in the cranial cavity, causing traction on cranial nerves and other structures like vessels which might be the cause of orthostatic headache.
SIH Headache

Who is more at risk for developing SIH Headache?

  • People who recently had a spinal tap or lumbar puncture.
  • People with weak connective tissue matrix as their Dura matter is thin and is more susceptible to tears and damage.
  • Females are more susceptible to get a SIH Headache.
  • Patient with repeated puncture attempts is more prone to getting a SIH headache.
  • People who have Chronic Tension Headache have also reported with more cases of SIH after a Spinal Tap.

Complications:

An undiagnosed mild case of SIH Headache can lead to New Daily Persistent Headache.

Severe leakage and decreased pressure can lead to:

  • Tremors
  • Disrupted Cognitive functions of Brain.
  • Unconsciousness
  • Coma.

Diagnosis

  • Proper history taking of patients with a complaint of SIH Headache will show a recent spinal tap or a lumbar puncture done.
  • A proper examination can also help with diagnosis.
  • CSF opening pressure is also determined.
  • MRI and CT scans are done to rule out any grave causes.

Management

Management entirely depends on the severity of symptoms and the patient’s compliance with the treatments involved.

Conservative Treatment:

  • Hydration: Staying hydrated can help increase the CSF volume.
  • Coffee: drinking coffee can provide relief.
  • Bed rest: As getting up triggers pain, complete bed rest is advised for at least 24 to 48 hours.

Medical treatment:

  • IV infusion: If a patient is unable to consume a lot of fluid by the oral route, intravenous fluids are given to raise the pressure.
  • Analgesics: Severe Acute pain can be treated by giving analgesics.
  • Epidural blood patch: A small amount of patient’s own blood is injected into the spinal cord over the puncture hole. The blood forms a clot sealing the hole and thus preventing more cerebrospinal fluid from flowing out. As CSF is constantly produced, normal pressure is restored in a few hours. People often report with Rebound Headaches after 6 months.

When to consult a doctor?

If the Headache doesn’t resolve within 48 hours of onset and you start experiencing dizziness, tinnitus, and visual disturbances, you must go to the ER as soon as possible.

FAQ

I got a spinal tap done a couple of days ago, now I have a headache that worsens upon standing up?

The cerebrospinal fluid leaks through the small puncture hole made for a spinal tap. Constant leakage decreases the pressure around the brain resulting in SIH Headache that usually increases upon sitting up or standing or straining like with Cough, Sneeze, or Exercise.

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What precautions can I take to avoid getting a Headache after Spinal Tap?

Hydrate yourself to keep replenishing the volume of CSF.

How effective is Epidural Blood Patch?

Epidural blood patch has a 30% success rate and is quite difficult to perform as it is difficult to locate the puncture hole. People often report with Rebound Headaches after 6 months.

Is Low blood Volume in any way related to SIH Headache?

Yes, Low blood volume for a long period of time can also affect the CSF volume and pressure and thus cause SIH Headache.