Spontaneous CSF leaks mimicking benign exertional headaches

Area of Science:

• Neurology
• Neurosurgery
• Radiology

Background:

• Spontaneous cerebrospinal fluid (CSF) leaks are increasingly recognized as a cause of various headache types.
• Traditionally, CSF leak headaches are characterized by orthostatic features, but atypical presentations are emerging.

Observation:

• Two cases of spontaneous CSF leaks presented with severe, intermittent headaches triggered by Valsalva-type maneuvers.
• These patients lacked orthostatic symptoms and were asymptomatic when avoiding provoking activities.

Findings:

• One patient with a cribriform plate leak was misdiagnosed with benign exertional headaches for six years.
• The second patient exhibited diffuse pachymeningeal enhancement and spinal meningeal diverticula, with a thoracic spine leak.

Implications:

• Headaches mimicking benign exertional headaches represent a newly recognized presentation of spontaneous CSF leaks.
• This broadens the clinical spectrum, necessitating consideration of CSF leaks in patients with exertional headache-like symptoms.
• Accurate diagnosis requires a comprehensive evaluation beyond typical orthostatic headache presentations.