Taking the history for suspected spinal cerebrospinal fluid leaks: A narrative review

Spinal cerebrospinal fluid (CSF) leaks, including spontaneous intracranial hypotension, can be difficult to diagnose, requiring a high level of suspicion. Although the diagnosis is obvious in patients presenting with a new onset of coat hanger, orthostatic headaches that improve quickly in recumbence, the symptoms can be much more nuanced. Patients often experience misdiagnosis and delayed diagnosis, particularly if their brain imaging is negative, resulting in a severely impacted quality of life. Thus, it is incumbent for clinicians to be aware of both common and uncommon manifestations of spinal CSF leaks and to consider the possibility of a spinal CSF leak in patients with atypical symptoms, chronic migraine unresponsive to multiple treatments, or new daily persistent headache. This article provides a strategy for taking a medical history focused on CSF leak symptoms to help improve diagnostic accuracy and initiate appropriate testing. Examples and a list of topics to discuss are included.