Case: 57-year-old Woman with Headache when Sitting Up

by Roy Strowd, MD

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    00:01 In this lecture, we're going to talk about headaches that are associated with pressure, both low and high pressure. Let's start with a case.

    00:09 This is a 57 year old women who has a past medical history if hypertension, diabetes, and a history of mild headaches.

    00:17 The headaches were well controlled until six weeks ago.

    00:20 Now she has developed bifrontal throbbing headaches that are relieved with lying down and worsened with sitting up, to the point where she does not want to get up in the morning as a result of initiation of a severe headache.

    00:34 She has no photo or phonophobia, no nausea, no vomiting.

    00:38 Initially, this was thought to be sinusitis and treated with antibiotics, but she's had no improvement. Her exam is normal.

    00:45 So what type of headache syndrome is this? Well, let's look at some of these key features.

    00:50 She's bifrontal throbbing headaches, many headaches can cause bifrontal throbbing, so not so specific to a precise diagnosis or etiology or group, but in the next part of the case, we see this positional component.

    01:06 These headaches are relieved with lying down and incited, initiated with sitting up and that prominent positional component is going to point us in the direction of a low pressure headache.

    01:18 Is this a primary or secondary headache syndrome? Well, this is a secondary headache syndrome.

    01:24 This is a low pressure headache, not the bifrontal nature, but that positional component suggest a secondary cause, a low pressure headache, and requires urgent evaluation.

    01:34 So this patient underwent additional imaging and here we're looking at the MRI of the brain with and without contrast.

    01:40 This is a T1-weighted gadolinium enhanced MRI, so this is after contrast has been given.

    01:47 We see the brain, it's very symmetric, the left looks like the right.

    01:50 What's abnormal on the MRI is the line, the white line that is around the patient's brain.

    01:56 It's almost drawing a line around where the dura would be the meninges, and we see diffused meningeal enhancement, diffused enhancement of the pachymeninges, the dura that covers the superficial surface of the brain and the cerebral vault, and this is diffused smooth pachymeningeal enhancement which is seen in this low pressure headache syndrome.

    02:20 So what's the treatment for this headache? Should we start acetazolamide? Start antibiotics with coverage for meningitis? Evaluate for spinal dural tear or refer to an ENT otolaryngologist? Well, for ENT, we really don't get a history of trauma or traumatic CSF leak that would have given rise to leaking of the CSF from the head and neck area so a referral to ENT is likely to be low yield in this patient that we're getting close to the potential etiology.

    02:54 Starting acetazolamide won't help.

    02:56 Acetazolamide is a medicine used for high pressure headaches, and this patient has a description of low pressure headaches.

    03:03 Acetazolamide will likely worsen this patient's headache syndrome.

    03:07 What about antibiotics? We see smooth dural enhancement, that's a finding we can see in meningitis, though imaging in meningitis tends to be focal.

    03:16 We don't tend to see this diffuse smooth pachymeningitis with an infectious process as we do with this low pressure headache, and so here, this suggests a noninfectious etiology.

    03:29 In addition, the patient is afebrile and not otherwise ill, which would be additional clinical symptoms that would point us in the direction of an infection.

    03:37 And so in this case, we should evaluate for a spinal dural tear.

    03:42 This case indicates a patient who's suffering from a low pressure headache.

    03:46 The headache is relieved by sitting down and present upon rising up, and we see the typical MRI findings of a low pressure headache, diffused dural thickening.

    03:56 And another sequences we may see, other classic feature that point us in this direction.

    04:03 Low pressure headaches can be caused by reduced CSF production or a leak where the spinal fluid is leaking out and there's less spinal fluid in the CSF space and that contributes to this patient's symptoms, and the best treatment is to block that leak and patients will have rapid recovery and resolution.

    About the Lecture

    The lecture Case: 57-year-old Woman with Headache when Sitting Up by Roy Strowd, MD is from the course Headache.

    Included Quiz Questions

    1. Diffuse, smooth, pachymeningeal enhancement
    2. Focal, patchy dural enhancement
    3. Lack of meningeal enhancement
    4. Brain edema
    5. Aneurysmal dilatation of the blood vessels
    1. A dural tear causing a CSF leak
    2. Overproduction of CSF
    3. Aggressive treatment of hypertension
    4. Infections such as meningitis
    5. A GI bleed causing hypotension

    Author of lecture Case: 57-year-old Woman with Headache when Sitting Up

     Roy Strowd, MD

    Roy Strowd, MD

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