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ARTICLES: Andrea N. Leep Hunderfund and Bahram Mokri Orthostatic headache without CSF leak Neurology 2008; 71: 1902-1906 [Abstract] [Full text] [PDF]

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Orthostatic headache without CSF leak

Francesco Bono, Aldo Quattrone   (23 February 2009)

Reply from the authors

Bahram Mokri, Andrea N. Leep Hunderfund   (23 February 2009)

Orthostatic headache without CSF leak 23 February 2009
Francesco Bono, Institute of Neurology, University "Magna Gręcia", Campus Universitario "S. Venuta", Viale Europa, 88100 Catanzaro, Italy, Aldo Quattrone Send Correspondence to journal: Re: Orthostatic headache without CSF leak f.bono{at}isn.cnr.it Francesco Bono, et al.	We read the article by Drs. Hunderfund and Mokri with great interest. [1] The authors described six patients with orthostatic headache and normal recumbent CSF opening pressure without CSF leak. The authors propose that one potential explanation for orthostatic headache is an increased compliance of the lower spinal CSF space which causes a decreased intracranial CSF pressure during vertical posture. Orthostatic decrease of CSF pressure thus leads to compensatory dilatation of pain sensitive intracranial venous structures which in turn causes orthostatic headache. We agree that this mechanism could explain orthostatic headache in this series of six patients. However, there is no direct evidence of orthostatic decrease of CSF pressure in this series and the authors did not measure CSF pressure in the upright position in their patients. We want to emphasize that the demonstration of orthostatic decrease of CSF pressure is needed to support this hypothesis. Hunderfund and Mokri did not cite our study that may further support their theory. [2] We described two patients with headache lasting 1-10 minutes that was only triggered by coughing when the patients assumed a vertical posture. [2] In these patients with orthostatic headache, we were able to demonstrate a decrease of lumbar CSF pressure in the upright position. By contrast, this finding was never observed in 25 controls in whom vertical posture always elevated their CSF pressures. In these patients, the findings might be explained by increased compliance of the lower spinal CSF space. As our patients did not have imaging abnormalities of intracranial hypotension or low recumbent CSF opening pressure, spontaneous intracranial hypotension was excluded. Our observation provides evidence that an orthostatic headache may be associated with orthostatic drop in lumbar CSF pressure. Our finding supports Hunderfund and Mokri's hypothesis that orthostatic drop of CSF pressure may play a role in inducing headache in patients with orthostatic headache and normal recumbent CSF opening pressure without detectable CSF leak. References 1. Leep Hunderfund AN, Mokri B. Orthostatic headache without CSF leak. Neurology 2008; 71:1902-1906. 2. Bono F, Giliberto C, Lavano A, et al. Posture-related cough headache and orthostatic drop in lumbar CSF pressure. J Neurol 2005; 252:237-238. Disclosure: The authors report no disclosures.
Reply from the authors 23 February 2009
Bahram Mokri, Mayo Clinic 200 1st St SW, Rochester, MN 55905, Andrea N. Leep Hunderfund Send Correspondence to journal: Re: Reply from the authors bmokri{at}mayo.edu Bahram Mokri, et al.	We thank Drs. Bono and Quattrone for their interest in our article. We agree with them that measuring the CSF opening pressure in supine and upright positions would be helpful. This information is not readily available in retrospective analyses but should be considered in prospective studies of orthostatic headache without CSF leak. We also thank them for highlighting their article and agree that their observation lends support to our hypothesis. Disclosure: The authors report no disclosures.