Low CSF Pressure Headache

Signs of Positional Headache Due to Insufficient Amounts of Cerebrospinal Fluid

Low cerebrospinal fluid (CSF) pressure headache is a type of positional headache that arises due to insufficient spinal fluid pressure on the brain.

The primary characteristic of low CSF pressure headache is pain that starts or worsens when you move your head or are upright and goes away when you lie down. This article provides a brief overview of low CSF pressure headache, including its causes, symptoms, diagnosis, and treatment.

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What Is a Low CSF Pressure Headache?

Low CSF pressure headache is a secondary headache disorder, meaning it’s caused by another condition, rather than arising independently. The symptoms come on due to insufficient amounts of cerebrospinal fluid, which protects the brain and spinal cord when you move.

The pain and other symptoms arise as the brain moves excessively and distresses surrounding nerves. This condition is sometimes also called a "positional headache" because it arises—and goes away—due to changes in the position of your head. With this type, the pain and other symptoms begin when you’re upright and go away when you’re lying down.

Symptoms

The primary symptom of positional headache due to low CSF pressure is head pain that gets worse when you stand up or move and eases off when you lie down. For some, it comes on quickly. For others, it has a more gradual onset.

Typically, the symptoms start within 15 minutes of being upright and go away 15–30 minutes after lying down. In some cases, however, the time between onset and getting relief can take one or more hours.

Pain with positional headache due to low CSF pressure ranges from dull and manageable to severe and debilitating. These headaches are:

  • Usually localized to the back of the head or base of the skull
  • Less often on the sides, face, or all over the head
  • On both sides of the head, as opposed to just one side
  • Often described as a “pulling back" from the head to the neck

In addition, these headaches may also cause:

  • Neck pain and stiffness
  • Nausea and vomiting
  • Light and sound sensitivity
  • Ringing in the ears (tinnitus) or hearing loss
  • Loss of balance
  • Fatigue
  • Pain between the shoulders or in the upper arms
  • Changes in vision
  • Dizziness and vertigo
  • Facial numbness
  • Changes in sense of taste

Complications

In rare cases, positional headache due to low CSF pressure can advance into serious neurological complications. This can cause symptoms that resemble those of more serious conditions, including:

  • Frontotemporal dementia, affecting the frontal and temporal lobes of the brain and causing personality, memory, and behavioral changes
  • Parkinson’s disease, a progressive neurological disease leading to tremors, slowed movements, rigidity, and loss of balance
  • Superficial siderosis, a chronic condition of the central nervous system (CNS) characterized by hearing loss, difficulty moving, and jerky movements    
  • Ataxia, loss of muscle control causing interrupted or affected walking or movement
  • Quadriplegia, paralysis of all four limbs
  • New daily persistent headache, a rare primary headache disorder that does not stop

Complicated cases can lead to loss of consciousness, coma (a state of prolonged unconsciousness), strokes (blood supply to the brain is interrupted or reduced), and even death.

What Causes Low CSF Pressure Headache?

Low CSF pressure headaches primarily occur due to insufficient levels of cerebrospinal fluid, the fluid that surrounds the brain and spinal cord, which make up the central nervous system. This is caused by a deformity or tear in the dura, which is the tough outermost layer of the tissues that surround the CNS, called the “meninges.”

What Is Cerebrospinal Fluid?

The central nervous system is surrounded by cerebrospinal fluid, a colorless liquid that delivers nutrients and takes away waste. CSF also serves to cushion the brain when you move your head.  

The CSF loss lowers the pressure it places on the brain, called “intracranial hypotension,” leaving this vital organ with less support. When standing or when upright, it sinks to a lower-than-natural position, which stretches the surrounding meninges and nerves, causing pain.

CSF leaks can be brought on by:

  • Dural sac tear, a complication of spinal surgery or epidural anesthesia (medicines to numb pain that are given in the epidural space around the spinal cord)
  • Spinal tap (lumbar puncture, removing CSF with a needle inserted between to vertebrae)
  • Head or neck trauma due to a fall or impact
  • Heavy sneezes or coughing

Other Causes of Positional Headaches

Positional headaches can also be signs of cervicogenic headaches, which are associated with problems in the neck. Issues can include deformity in the structure of the vertebrae in the neck, compaction with the disks between them, and problems with nerves and blood flow, among others.

Another cause of low CSF pressure headaches is postural orthostatic tachycardia syndrome (POTS), a condition caused by changes or abnormalities in the autonomic nervous system (dysautonomia) that results in unpleasant symptoms brought on by standing up. POTS can cause headaches that can be confused with headaches due to low CSF pressure, and they may even coexist in someone with low CSF pressure.

Risk Factors

Although all people can develop positional headaches due to low CSF pressure, those who have weaker meninges, or “weakened connective matrix,” are more prone to developing them. This is experienced more often in women than men and in people who are double-jointed, tall and thin, very flexible, or who have a skinny neck.  

Diagnosing Low CSF Pressure Headaches

Low CSF pressure headaches are typically treated by interdisciplinary teams that, depending on the case, may include neurologists, neurosurgeons, pain specialists, emergency medicine physicians, anesthesiologists, and geneticists, along with your primary care provider. Diagnosis of this condition can be tricky, especially when the symptoms are not very severe.

Several tests and procedures may be involved, including:

  • Assessment of symptoms: You’ll first undergo physical evaluation and talk about your symptoms, the medications you’re taking, and your health history.
  • Magnetic resonance imaging (MRI): MRI relies on a magnetic field and radio waves to create two- or three-dimensional images of structures inside your body. Brain MRI, often paired with an injected dye, can assess the meninges, looking for irregularities or signs of the brain sagging. This type of imaging can also help healthcare providers detect leaks in the spinal cord.
  • Computerized tomography (CT) myelogram: Another form of imaging that uses a contrast dye to help in viewing images, CT myelogram takes several X-rays of the spine. This is effective in revealing the location of rips or tears in the spinal meninges.
  • CSF cisternogram: A radioactive dye is injected into the CSF surrounding the spinal cord, which allows a specialized camera to locate the site of the tear in the meninges. In some cases, CSF cisternogram is only able to locate the general area of the problem.     
  • Spinal tap: A spinal tap can detect if there is low intracranial pressure, indicating a positional headache. The healthcare provider injects a needle in between bones of the lower (or lumbar) spine, taking a small sample. This test is less precise than the others.

 Treatment

Treatment for positional headaches due to low CSF pressure can be challenging since most standard headache therapies don’t work. Therapy is successful when the hole or malformation in the spinal meninges is closed up, stopping the CSF leak. There are several interventions that doctors try.

Rest and Recovery

As noted, lying down for some time should relieve the headache. The first line of treatment for milder cases involves bed rest, drinking more water, and taking caffeine (either in the form of coffee or tea or as pills). Given time, some cases resolve without additional treatment.

Epidural Blood Patch

If the headache doesn’t resolve on its own, an epidural blood patch procedure is the standard treatment. The specialist, usually an anesthesiologist, takes blood from a vein and injects it near the hole in the meninges or at a safe distance if the exact location is unknown.

This blood forms a clot at the rupture, providing nearly instantaneous relief of symptoms. This therapy can be repeated multiple times, if needed.

Surgical Repair

If the exact location of the tear in the meninges is known, repair of the site can be considered. Using X-ray imaging as a guide, an interventional radiologist can use a specialized needle to deliver adhesive to the tear. If there’s a larger tear in the spine, a neurosurgeon may attempt surgery to repair it.

Rebound Intracranial Hypertension Headache

In rare cases, the pressure on the brain and spine becomes elevated following treatment for low CSF pressure headaches. Called “rebound intracranial hypertension headache,” this can cause a range of symptoms, including:

  • Frequent, severe headache
  • Nausea and vomiting
  • Blind spots in the field of vision
  • Pain behind the eye
  • Tinnitus
  • Neck stiffness
  • Pain in the arms and legs
  • Memory problems

Treatments for this condition include lifestyle modifications or taking medications such as Diamox (acetazolamide) and Topamax (topiramate).

When to Seek Medical Attention

Medical care is called for if you experience low CSF pressure headache symptoms, and certainly if you experience the other symptoms of a CSF leak. Get help if you experience:

  • Worsening headache
  • Very rapid onset of severe headache
  • Neck pain and stiffness
  • Problems staying in balance, dizziness, vertigo
  • Ringing in the ears
  • Facial pain
  • Visual disturbances, double vision
  • Pain between the shoulder blades and/or in the arms
  • Racing heartbeat when changing position
  • Memory and speech problems

Summary

Low CSF pressure headaches may arise due to insufficient cerebrospinal fluid pressure on the brain, which can occur due to a dural sac tear, spinal tap, trauma of the head or neck, or heavy sneezes or coughing. This type of headache is characterized by pain and other symptoms when you’re upright, which then go away when you’re lying down.

Low CSF pressure headaches are usually treated by an interdisciplinary team of neurological experts using a variety of imaging techniques. Treatment depends on the severity of the condition, usually incorporating rest and relaxation. An epidural blood patch and surgical repair can also be used.

A Word From Verywell

When it comes to health issues like low CSF pressure headaches, it’s important to get timely help. The sooner you get care, the better off you’ll be. Though the condition is sometimes difficult to detect and manage, therapies are often successful. It’s worth exploring what you can do to live free of low CSF pressure headache pain and discomfort.  

Frequently Asked Questions

  • Why do I wake up with a headache?

    Wake-up headaches arise due to sensitization or changes in the activity of your hypothalamus, the part of your brain associated with pain and your circadian rhythm (your sleep-wake cycle). Conditions that disrupt this activity include:

    • Sleep apnea (breathing repeatedly stops and starts during the night)
    • Insomnia, other sleep disorders, or insufficient sleep
    • Migraine headache
    • Teeth grinding (bruxism)
    • Hangover
    • Tension headache (due to head position)
    • Certain medication side effects
  • When should I worry about a headache?

    While most headaches aren’t signs of dangerous underlying conditions, there are several signs that they might be. Call your doctor if:

    • Your headaches get worse when standing up and improve when you lie down.
    • Your headaches come on very rapidly and are very painful.
    • You experience neurological symptoms, such as brain fog.
    • Your personality or mood has changed.
    • You have nausea or you vomit when experiencing headaches.
    • You had a fall or impact to the head that caused loss of consciousness.
    • You have headaches that wake you up from sleep.
    • You have pain and/or redness in one eye.
  • What should you take for a headache when pregnant?

    Most over-the-counter (OTC) and prescription medications for headaches aren’t safe for pregnant people to take. Tylenol (acetaminophen) has traditionally been considered a good option for this population. However, researchers now urge caution with this medication as well.

    Healthcare providers recommend staying hydrated, taking caffeine (in some but not all cases), and incorporating lifestyle changes. In very difficult cases, nerve block or other neurostimulation methods may be considered.

9 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Johns Hopkins Medicine. Low CSF headache.

  2. Friedman D. What to know about low-pressure headaches. American Migraine Foundation.

  3. Deline C, Schievink W. Spontaneous intracranial hypotension. National Organization for Rare Diseases.

  4. American Migraine Foundation. What is cervicogenic headache? How do you treat it?.

  5. Farris B, O'Brien J. Idiopathic intracranial hypertension. National Organization for Rare Disorders.

  6. Harvard Health. Headache pain: When to worry, what to do. Harvard Health Publishing.

  7. Ryan T. What is causing your morning headache?. Sleep Foundation.

  8. Bauer AZ, Swan SH, Kriebel D, et al. Paracetamol use during pregnancy — a call for precautionary actionNat Rev Endocrinol. 2021;17(757–766). doi:10.1038/s41574-021-00553-7

  9. American Headache Society. Treating migraine during pregnancy. Published 2021.

Additional Reading

By Mark Gurarie
Mark Gurarie is a freelance writer, editor, and adjunct lecturer of writing composition at George Washington University.