1. Nursing Instruction
  2. Overview
  3. Neurology
Major point
  1. Headache caused by spontaneous intracranial hypotension is also known as low-pressure headache.
  2. Common symptoms include severe headache, nausea, and vomiting, especially when standing or sitting upright.
  3. When positional headaches (orthostatic headaches) occur, it is recommended to lie down, stay well hydrated, and consume caffeine.
I. What is spontaneous intracranial hypotension (SIH)?
    Spontaneous intracranial hypotension (SIH), also known as low-pressure headache, is characterized by the leakage of cerebrospinal fluid (CSF) caused by a tear in the dura mater, resulting in positional headaches. The diagnostic approach includes using magnetic resonance imaging (MRI) of the brain and spine to locate the site of the fluid leak.
    Spontaneous intracranial hypotension usually affects young adults and is more common in women than in men. In most cases, there is no obvious cause; however, some cases develop after procedures such as lumbar puncture, epidural anesthesia, or spinal injuries caused by physical activities, heavy lifting, or falls.

II. What are the common symptoms of SIH?
  1. Positional headache (orthostatic headaches): The headache worsens immediately after standing or sitting and improves significantly when lying down. The pain may be located at the back, front, or all over the head.
  2. Neck pain or stiffness: The pain may spread downward and sometimes lead to lower back pain.
  3. Other symptoms: Some patients may experience dizziness, ringing in the ears (tinnitus), nausea, vomiting, and hearing loss. Visual problems such as double vision (diplopia), blurred vision, and sensitivity to light are also common. In serious cases, complications like subdural hemorrhage may occur, with symptoms including consciousness blurred or weakness in the limbs.
Having the above symptoms does NOT necessarily mean that you have SIH. Therefore, a detailed clinical inspection and examinations were warranted before the correct diagnosis, you can go to the neurology clinic for evaluation.
 
III. What are the common treatments for SIH?
  1. Conservative treatment: A few spontaneous intracranial hypotension cases recover spontaneously within weeks to months. The main conservative approaches include bed rest, staying well hydrated, and consuming caffeine-containing beverages such as coffee or green tea. These methods help maintain brain pressure and replenish lost cerebrospinal fluid.
  2. Epidural blood patch: Since natural recovery usually takes a long time, the epidural blood patch is now a common treatment. By interpreting MRI images, the anesthesiologist can locate the exact site of the CSF leak. During the procedure, the doctor draws about 20 to 40 ml of the patient’s blood and injects it into the epidural space near the leak to form a clot. This intervention effectively reduces CSF leakage, relieves headaches, shortens hospital stays, and lowers the risk of serious complications such as subdural hemorrhage.
  3. Dural repair surgery: If there is still no improvement after several repeated epidural blood patches, dural repair surgery may be considered after consultation with the doctor.
  4. Subdural hematoma evacuation: The most serious complication of spontaneous intracranial hypotension is subdural hemorrhage (SDH), which results from severe CSF leakage. Depending on the severity, an emergency epidural blood patch will be promptly performed. Meanwhile, a neurosurgeon will be obtained to consider hematoma evacuation, which can help prevent life-threatening complications such as brainstem compression.
IV. Self-care for spontaneous intracranial hypotension
  1. Daily care for headache caused by spontaneous intracranial hypotension:
    1. Keeping a lying-down position: Since headaches caused by spontaneous intracranial hypotension usually worsen when standing or sitting, it is recommended to rest lying down as much as possible
    2. Avoid straining or breath-holding: Activities that involve straining or breath-holding may worsen the CSF leak.
    3. Stay well hydrated: Aim to intake fluid  between 1,500 and 3,000 ml of water daily,or follow your doctor’s advice.
    4. Consume caffeine or caffeine-containing beverages: Caffeine helps increase intracranial pressure and alleviate headaches.
  2.  Post-Epidural blood patch care:
    1. Keep absolute bedrest: Keep absolute bedrest for 24–72 hours after the procedure to help stabilize the blood patch. The exact duration of bedrest will be determined by your doctor based on clinical judgment.
    2. Movements to Avoid: Avoid certain movements such as nodding, shaking the head, bending over, stretching the back, straining, or lifting heavy objects (over 5 kg). These actions may cause spinal flexion and potentially lead to a recurrence of CSF leakage.
    3. Instruction or getting out of bed: After 24 to 72 hours of bed rest, gradual mobilization and resumption of daily activities may be initiated. To safely get out of bed, first, move the body to the edge of the bed and roll onto the side. Next, let the legs hang over the edge. Then, use the arms to push up into a seated position. After that, stabilize in a sitting position. Finally, stand up slowly. Furthermore, monitoring of headache severity is also important.
    4. Infection prevention: Keep the puncture site clean and dry, and monitor for any signs of infection, such as redness, swelling, warmth, or pain.
    5. Other important notes: If new numbness, muscle weakness in the limbs, worsening headache, or swelling at the puncture site occurs, please inform the medical staffs as soon as possible.
Reference
  1. Cheema, S., Mehta, D., Qureshi, A., Sayal, P., Kamourieh, S., Davagnanam, I., & Matharu, M. (2024). Spontaneous intracranial hypotension. Practical Neurology, 24(2), 98-105. https://doi.org/10.1136/pn-2023-003986
  2. Dalby, S. W., Smilkov, E. A., Santos, S. G., Olesen, V., Skjolding, A. D., Vukovic‐Cvetkovic, V., ... & Schytz, H. W. (2025). Spontaneous intracranial hypotension—Neurological symptoms, diagnosis, and outcome. European Journal of Neurology, 32(1), e16579. https://doi.org/10.1111/ene.16579
  3. Mehta, D., Cheema, S., Glover, S., Qureshi, A. M., Davagnanam, I., Kamourieh, S., ... & Matharu, M. S. (2025). Defining the typical characteristics of orthostatic headache in patients with spontaneous intracranial hypotension. Cephalalgia, 45(1), 03331024241308154. https://doi.org/10.1177/03331024241308154

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