[Severe orthostatic headache: a retrospective study on clinical presentation, radiological characteristics, and...

To determine clinical characteristics and therapeutic outcome of severe orthostatic headache, we retrospectively studied 12 consecutive patients with severe orthostatic headache and unremarkable medical history. Headache is defined as severe when it interferes with patient's daily activities. Baseline characteristics of our patients are essentially similar to those reported in other published series of spontaneous intracranial hypotension: female preponderance; mean age of approximately 40 years; frequently associated nausea, hearing disturbances, or vertigo. Diffuse pachymeningeal gadolinium enhancement was demonstrated on MRI in 64% of the patients. Low CSF pressure was present in 78%. Of 8 patients underwent radionuclide cisternography, CSF leak site was identified in 4 patients. Severe orthostatic headache resolved in 13.6 days in 5 patients who received supportive measures only. Conservative treatment was ineffective in 7 patients. Of 6 patients treated with epidural blood patch (EBP), 5 patients (83%) responded well to the first EBP. Patients with severe orthostatic headache which persisted 2 weeks and longer in spite of conservative measures are candidate for EBP. Our study and a literature review suggest that at least 2 EBPs should be performed for each leak site. Studies with more patients are needed for establishing a better treatment protocol for this syndrome.