Spontaneous intracranial hypotension presenting as a chronic daily headache.

To cite: Lobo R, Kiely P, Watts M, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013009356 DESCRIPTION A 51-year-old male was referred by his general practitioner with a 9-month history of chronic daily headache, affecting the frontal and vertex areas of the head. T1-weighted MRI with gadolinium enhancement showed diffuse pachymeningeal enhancement (figures 1 and 2). He subsequently had a lumbar puncture, and the opening pressure was 3.5 cm in the cerebrospinal fluid (CSF), confirming intracranial hypotension. The CSF constituents were normal. When the history was revisited, it was noted that the patient had for the first 2 months postural-related headaches; however, over time, it turned into a chronic daily headache. The patient was also an avid golfer, which could have been the precipitant of a dural sleeve tear leading to low intracranial pressure. The reduction in CSF pressure results in traction on the anchoring and supporting structures of the brain, resulting in a headache. In the upright position, this traction is exaggerated, hence the postural component of the headache. However, during the course of the illness, the orthostatic component may disappear, and a chronic daily headache may develop (as in this case). Investigations for spontaneous intracranial hypotension include MRI of the brain with gadolinium enhancement to assess for the typical features of this syndrome, which are diffuse pachymeningeal enhancement (see figures 1 and 2 above), ‘sagging’ of the brain, tonsillar descent and posterior fossa crowding. Treatment for spontaneous intracranial hypotension includes conservative measures such as bed rest, oral or intravenous rehydration to restore CSF volume and oral caffeine intake. When conservative measures fail or in patients with severe headache, an epidural blood patch may be used.