Recent EMRAP podcast reminded me of a case from when I was a Medical Officer in the Navy.

One of my Marines, early twenties, with no medical problems presented for follow up in sick call after being seen in the emergency department for a headache.  Since it was the worst headache of his life, an LP was performed.  Both the LP and the CT head were negative. He was given standard headache treatment with “migraine cocktail” from what I remember, however, no significant relief.

He presented to clinic with complaint of ongoing headache that was only better if he laid completely flat with excruciating pain with sitting up.   He refused to do anything other than lay on the gurney in the treatment room.

His presentation was classic for post LP headache, however, he states that this was the same headache that he presented to the ED for the previous evening and was not changed by the LP.  He was adamant about this timeline and unchanging symptoms after LP. Physical exam was normal to include normal Neuro exam.

I subsequently called the Neurologist on call at Naval Hospital, who stated the likely diagnosis was a “spontaneous CSF leak” and recommended a blood patch.  I was quite confused as I had never heard of such and it seemed like a made up diagnosis to me at the time.   I did, however,  want to help my patient and for him to leave the clinic at some point that day.  I then called anesthesia who was agreeable to the blood patch given recent LP and current exam/symptoms.   The patch lead to resolution of his symptoms and he was able to stand up and walk without a headache.

This is the only case that I have seen, however, the recent EMRAP review leads me to believe that I might see another case while practicing Emergency Medicine.

SIH is caused by a spontaneous tear in the dura in the spine or elsewhere in the meninges and leads to intracranial hypotension from CSF leak.  Symptoms are incredibly similar to post LP headache given the pathophysiology on really differ in that CSF leak in an LP is iatrogenic and SIH is well, spontaneous.  Diagnosis can be by LP, which will demonstrate low opening pressure, or MRI of the Brain W/WO and Spine W/O which will demonstrate the leak.  The symptoms are similar regardless of the level at which the leak occurs so you may have scan the entire meninges to find it.

Treatment initially is caffeine and rest for mild-moderate headaches and lumbar blood patch for moderate-severe headaches.

Uptodate has a lengthy but throughouh algorithm for diagnosis and treatment.   If lumbar patch doesn’t work, a more targeted approach may need to be employed.

• Take-home point – consider SIH when someone presents with post LP headache symptoms without having had one performed in the recent past.