Understanding Positional Headache : Symptoms, Causes, Diagnosis, and Treatment

Positional headache is a type of headache that occurs on changing position, particularly when standing up or sitting down. It is also known as an orthostatic, postural, and low-pressure headache. There is throbbing pain in the head, neck, and upper back and accompanied by dizziness, nausea, and sensitivity to light and sound.

Positional headache occurs due to changes in the pressure within the skull and spinal fluid. This can be due to a variety of conditions including cerebrospinal leak, intracranial hypotension, or tension headaches.⁽¹⁾ These conditions decrease the pressure of the fluid that surrounds the brain and spinal cord. This can cause pain and other symptoms associated with positional headaches.

Positional headache is not always a serious condition but can indicate an underlying medical condition that requires treatment. It is important to seek medical attention if a person experiences a positional headache that worsens with changing positions.

Addressing positional headaches is important for several reasons:

• To improve the quality of life of a person because positional headache can be extremely uncomfortable.⁽⁵⁾
• There are numerous serious conditions such as spinal cord tumors or intracranial hypotension that may cause positional headache and if left untreated can harm seriously. Addressing positional headache can help prevent these complications.
• Also, addressing this condition can help reach the cause of it and correct the conditions.

Addressing positional headache can be helpful in relieving the symptoms, coming to an accurate diagnosis, and improving the quality of life of an individual.

In positional headache the pain is worse when the person is upright and goes away as they lie flat for around 20-30 minutes.

Some people may wake up in the morning with mild headache worsening throughout the day.

In positional headache there is pain in the back of the head. It can also affect the front of the head.

The symptoms of positional headache include:

• Dull, aching, and throbbing headache located in the back of the neck.
• Worsening of pain with movement
• Relief from pain on lying down
• Sensitivity to light and sound
• Nausea and vomiting
• Neck stiffness
• Dizziness and lightheadedness
• Pain in the temples

Not all people with positional headache experience the same symptoms. It is important to identify the symptoms and seek medical attention for the detection of the cause and appropriate treatment.

There are a variety of factors that may cause positional headache.

• Low Cerebrospinal Fluid Pressure: This is the most common cause of positional headache.⁽⁶⁾ It occurs when the pressure in the cerebrospinal fluid that surrounds the brain and spinal cord is too low. This causes the brain to sag and pull on pain-sensitive structures in the head or spine.
• High Cerebrospinal Fluid Pressure: Though rare, high CSF pressure can also cause headache when a person is in an upright positio.⁽⁷⁾
• Dehydration: Lack of water intake can lead to dehydration which can lead to headache. This can cause headache when standing in an upright position.
• Side Effects of Medications: Some blood pressure medications can cause positional headache as a side effect.
• Problems with Spine and Neck: Issues with the neck or spine such as herniated disc or spinal stenosis can cause headache that worsens on changing positions.
• Infection and Inflammation: Infection or inflammation in the brain and spinal cord can cause positional headache.
• Tumors: Tumors of the brain and spinal cord can cause positional headache.
• Postural Orthostatic Tachycardia Syndrome: This condition involves dysfunction of the autonomic nervous system that regulates the processes of the heart and fluid balance. It leads to rapid heartbeat and blood pressure changes when a person is standing. It occurs when someone with a CSF leak or any other debilitating condition is asked to remain bedridden for a long period of time.

Postural orthostatic tachycardia syndrome is mostly seen affecting females between the ages of 15-50 years.⁽¹⁾

While going ahead with testing to diagnose positional headache, the doctor needs to rule out a CSF leak.

The tests to detect CSF leaks include MRI scans and CT myelography. MRI uses some strong magnetic field to create images that reveal typical CSF leak patterns in 80% of cases.⁽²⁾

Some of the common tests for diagnosing positional headache include:

• Lumbar Puncture: This is also known as a spinal tap and involves removing a small amount of cerebrospinal fluid from the lower back. The test can help determine if there is any abnormal pressure or presence of infection in the cerebrospinal fluid.
• Blood Test: Blood tests can be performed to detect medical conditions including anemia, which may be a cause of headache.
• Tilt Table Test: This test involves monitoring blood pressure and heart rate while lying down and slowly tilting a person upright to see if it triggers a headache.

After determining the cause of the positional headache, appropriate treatment can be recommended by the doctor.

The treatment of positional headache depends on the cause of it. The treatment of CSF leaks may depend on the severity and location of the leak.

Mild to moderate CSF cases respond well to lifestyle changes.

The treatment option for positional headache include:

• Rehydration: Increasing fluid intake can be helpful in alleviating symptoms if dehydration is the cause.
• Medications: Over-the-counter pain medications can be helpful in relieving pain. Sometimes medications are prescribed to manage the symptoms of CSF leaks. Researchers are yet to prove the effectiveness of these medications.⁽³⁾ These medications include theophylline, antinausea medications, and non-opiate pain medications.
• Epidural blood patches: In case of low CSF pressure epidural blood patches are performed. It involves injecting a small amount of the patient’s own blood into the spinal canal to increase the CSF pressure.⁽⁴⁾ The blood forms a clot that creates patches on the outer layer of the meninges. This stops the CSF loss.

If the exact location of the leak is not found, an epidural patch is performed in the middle and lower parts of the spine. Strenuous activities should be avoided 4-6 weeks after undergoing the epidural blood patch procedure.

• Physical Therapy: Neck and spine problems also cause headaches. In such cases, physical therapy can prove to be effective.
• Surgery: In chronic cases, or in cases where the precise location of leaks is known, surgery is performed.

Different surgeries are necessary to remove or repair structural abnormalities, which include tumors, malformations, or abnormal growths.

A few tips that can be helpful in preventing positional headaches include:

• Staying hydrated, as keeping the body hydrated helps in maintaining adequate CSF volume and pressure.
• Avoiding changing position or sudden changes in movements.
• Maintaining good posture, which means keeping the head and neck in a neutral position.
• Avoiding caffeine and alcohol intake as these substances cause dehydration and affect CSF levels.
• Wearing a neck brace or a collar to provide support to the neck and prevent CSF leakage.

Positional headache is a challenging condition to manage and several steps can be taken to prevent it. It is important to consult a doctor for early diagnosis and treatment and to reduce the risk of serious complications.

A doctor can look for the possible signs of emergency care, which include the warning signs of CSF leaks as follows:

• Nausea and vomiting
• Balance problem
• Neck pain and stiffness
• Brain fog
• Facial pain and numbness
• Dizziness and vertigo
• Ringing in the ear
• Pain and numbness in the arms and below them
• Facial pain and numbness
• Fatigue
• Fainting on standing up
• Racing heartbeat

Treatment for most CSF leaks is successful, but people continue to have symptoms and persistent disability, even after several treatments.

There is no treatment for postural orthostatic tachycardia syndrome, if that is the cause home treatment and medication can help manage the condition. It is therefore important to make an appointment with a healthcare provider to known about the cause of positional headache and get treated appropriately.