Intracranial hypotension is one of the most common causes of orthostatic headache, usually accompanied by other position-dependent symptoms, such as tinnitus and dizziness.
Case report.
A 49-year-old man with dyslipidemia and smoking habits presented to the emergency department with a three-month history of progressively worsening occipital headache, described as pressure-type, moderate-to-severe intensity, accompanied by nausea and dizziness, occurring exclusively when upright. He could maintain an upright position for only ten minutes before severe symptoms began and experienced immediate relief when lying down. His neurological examination, including fundoscopy, was normal.
During hospitalization, an MRI revealed no signs of CSF hypotension or a CSF leak. No improvement after five days in recumbent position, with fluids, caffeine and fixed analgesia. An epidural blood patch (20 mL of autologous blood) was performed without benefit. A bupivacaine bilateral greater occipital nerve block was also performed without improvement. A lumbar puncture showed an opening pressure of 13 cmH2O with normal cytochemical analysis. Cardiology was consulted, and both exercise stress test and tilt test were normal. An angio-CT and dynamic Doppler study of the cervical and intracranial vessels ruled out vertebrobasilar insufficiency.
The final hypothesis was a somatoform/functional disorder, with no key precipitant identified. Later, during an emergency visit for other symptoms, the patient admitted being treated for pathological gambling, which resolved his symptoms.
After a month of investigations for suspected intracranial hypotension, during which all diagnostic and therapeutic options were exhausted, serious and treatable pathologies involving parenchyma, vessels and CSF were excluded. Despite the specificity of the symptoms, this case highlights the necessity of considering a broad range of differential diagnoses and value the patient entire context.