Low Pressure Headache / Spontaneous Intracranial Hypotension¶

VERSION: 1.1 CREATED: January 30, 2026 REVISED: January 30, 2026 STATUS: Draft - Pending Review

DIAGNOSIS: Low Pressure Headache / Spontaneous Intracranial Hypotension (SIH)

ICD-10: G96.00 (Cerebrospinal fluid leak, unspecified), G96.01 (Cranial cerebrospinal fluid leak, spontaneous), G96.02 (Spinal cerebrospinal fluid leak, spontaneous), G97.0 (Cerebrospinal fluid leak from spinal puncture), G96.08 (Other cranial cerebrospinal fluid leak), G96.09 (Other spinal cerebrospinal fluid leak), G96.810 (Intracranial hypotension, unspecified), G96.811 (Intracranial hypotension, spontaneous), G96.819 (Other intracranial hypotension), G44.51 (Headache attributed to intracranial hypotension)

CPT CODES: 62270 (Lumbar puncture, diagnostic), 62272 (Therapeutic spinal puncture), 62273 (Epidural blood patch), 72141 (MRI cervical spine without contrast), 72146 (MRI thoracic spine without contrast), 72148 (MRI lumbar spine without contrast), 72156 (MRI cervical spine with and without contrast), 72157 (MRI thoracic spine with and without contrast), 70553 (MRI brain with and without contrast), 72240 (CT myelography, cervical), 72255 (CT myelography, thoracic), 72265 (CT myelography, lumbar), 78630 (Cisternography, radionuclide), 62320 (Epidural injection, cervical/thoracic), 62322 (Epidural injection, lumbar/sacral)

SYNONYMS: Spontaneous intracranial hypotension, SIH, low CSF pressure headache, CSF leak headache, CSF hypovolemia, intracranial hypotension, orthostatic headache, postural headache, post-dural puncture headache, PDPH, post-LP headache, post-lumbar puncture headache, spinal headache, CSF fistula, dural tear headache, spontaneous CSF leak, meningeal diverticulum leak, spinal CSF leak, low-pressure syndrome, CSF hypotension syndrome, spontaneous spinal CSF leak, pachymeningeal enhancement headache, brain sagging, cerebral ptosis, sinking brain syndrome

SCOPE: Evaluation and management of headache due to low cerebrospinal fluid pressure in adults. Covers spontaneous intracranial hypotension (SIH), post-lumbar puncture headache (PDPH), and post-surgical/post-traumatic CSF leaks. Includes diagnostic workup (MRI brain, MRI spine, CT myelography, cisternography), conservative management, epidural blood patch, and surgical repair for refractory cases. Excludes cranial CSF rhinorrhea/otorrhea from skull base defects (managed by otolaryngology/neurosurgery), and CSF leaks secondary to VP shunt overdrainage.

DEFINITIONS:

Spontaneous Intracranial Hypotension (SIH): Low CSF pressure (<6 cm H2O) or CSF hypovolemia from spontaneous spinal CSF leak, causing orthostatic headache and characteristic MRI findings
Post-Dural Puncture Headache (PDPH): Headache occurring within 5 days of lumbar puncture or spinal anesthesia, typically orthostatic, due to persistent dural rent and CSF leak
Orthostatic Headache: Headache that worsens significantly within 15 minutes of assuming upright posture and improves within 15-30 minutes of recumbency
Epidural Blood Patch (EBP): Injection of autologous blood into the epidural space to seal a dural defect and restore CSF volume
Pachymeningeal Enhancement: Diffuse, smooth, non-nodular dural enhancement on gadolinium-enhanced MRI, characteristic of intracranial hypotension
CSF Hypovolemia: Reduction in total CSF volume causing brain sagging and traction on pain-sensitive structures, even when opening pressure may be normal
Dural Ectasia: Weakness and ballooning of the dural sac, often associated with connective tissue disorders, predisposing to CSF leaks
CSF-Venous Fistula: Abnormal connection between a spinal nerve root sleeve and an adjacent epidural vein, causing CSF drainage into the venous system

PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP¶

1A. Essential/Core Labs¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
CBC with differential (CPT 85025)	Baseline; rule out infection or anemia contributing to symptoms	Normal	URGENT	ROUTINE	ROUTINE	URGENT
CMP (CPT 80053)	Electrolytes, renal function; baseline before IV fluids and medications	Normal	URGENT	ROUTINE	ROUTINE	URGENT
Coagulation studies (PT/INR, aPTT) (CPT 85610, 85730)	Required before epidural blood patch or lumbar puncture; assess bleeding risk	Normal coagulation	URGENT	ROUTINE	ROUTINE	URGENT
ESR (CPT 85652) / CRP (CPT 86140)	Rule out inflammatory or infectious cause of meningeal enhancement	Normal	URGENT	ROUTINE	ROUTINE	URGENT
Pregnancy test (beta-hCG) (CPT 84703)	Affects imaging decisions (gadolinium, CT myelography) and treatment	Document status	STAT	STAT	ROUTINE	STAT

1B. Extended Workup (Second-line)¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
TSH (CPT 84443)	Hypothyroidism can cause headache; rule out secondary cause	Normal	-	ROUTINE	ROUTINE	-
Magnesium (CPT 83735)	Low magnesium can worsen headache; contributes to muscle cramps	>1.8 mg/dL	URGENT	ROUTINE	ROUTINE	URGENT
Blood cultures (CPT 87040)	If febrile or concern for meningitis/epidural abscess mimicking SIH	No growth	URGENT	ROUTINE	-	URGENT
Connective tissue markers (if recurrent SIH)	Marfan, Ehlers-Danlos screening; associated with dural weakness	Document	-	-	EXT	-

1C. Rare/Specialized (Refractory or Atypical)¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Genetic testing for connective tissue disorders	Recurrent SIH in young patients; EDS, Marfan syndrome evaluation	Document	-	-	EXT	-
Beta-2 transferrin (nasal or ear fluid)	Confirm CSF vs. other fluid if rhinorrhea or otorrhea present	Positive = CSF leak	URGENT	ROUTINE	ROUTINE	URGENT
CT cisternography with intrathecal contrast	Localize CSF leak site when MRI and CT myelography are inconclusive	Identify leak site	-	EXT	EXT	-

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRI brain with and without gadolinium (CPT 70553)	First-line diagnostic study; perform urgently if SIH suspected	Diffuse pachymeningeal enhancement, brain sagging, subdural collections, pituitary engorgement, venous distension sign	Pacemaker, metal implants; gadolinium contraindicated in severe renal impairment (eGFR <30)	URGENT	URGENT	ROUTINE	URGENT
CT head without contrast (CPT 70450)	If MRI unavailable; rule out subdural hematoma, hemorrhage	Rule out SDH, hemorrhage; CT often normal in SIH	None in emergency	STAT	URGENT	-	STAT

2B. Extended (Leak Localization)¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRI total spine with and without contrast (CPT 72156, 72157, 72158)	After brain MRI confirms SIH; localize leak level	Epidural fluid collections, meningeal diverticula, dural ectasia, nerve root sleeve irregularity, extradural CSF	Pacemaker, metal implants	-	URGENT	ROUTINE	-
CT myelography (intrathecal contrast) (CPT 72240, 72255, 72265)	Gold standard for leak localization; after failed blind EBP or before targeted treatment	Contrast extravasation at leak site; epidural contrast pooling	Contrast allergy, coagulopathy, infection at injection site	-	URGENT	ROUTINE	-
Dynamic CT myelography	Fast CSF leaks not captured on conventional CT myelo; rapid-sequence imaging after intrathecal injection	Active contrast extravasation during imaging	Same as CT myelography	-	EXT	EXT	-
Digital subtraction myelography (DSM)	CSF-venous fistula detection; gold standard for CVF when CT myelography negative	CSF-venous fistula (contrast filling epidural vein)	Same as CT myelography; requires interventional suite	-	EXT	EXT	-

2C. Rare/Specialized¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
Radionuclide cisternography (CPT 78630)	Confirm CSF leak and assess CSF dynamics; less precise for localization	Early bladder activity (<4 hours), absent activity over convexities at 24-48 hours, parathecal activity	Intrathecal injection contraindications	-	EXT	EXT	-
MR myelography (heavily T2-weighted)	Non-invasive leak localization; useful for epidural collections and meningeal diverticula	Extrathecal fluid signal along spine	Pacemaker, metal implants	-	ROUTINE	ROUTINE	-
Intrathecal gadolinium MRI (off-label)	Slow leaks not detected by CT myelography; high sensitivity	Gadolinium extravasation at leak site	Off-label use; requires informed consent; use low dose (0.5 mL gadoteridol)	-	EXT	EXT	-

MRI Brain Findings in SIH (Diagnostic Reference)¶

Finding	Significance	Sensitivity
Diffuse pachymeningeal (dural) enhancement	Most characteristic finding; smooth, non-nodular, bilateral	~83%
Brain sagging / downward displacement	Cerebellar tonsillar descent, flattening of pons, effacement of prepontine cistern	~50-75%
Subdural collections (hygromas or hematomas)	Traction on bridging veins; may require evacuation if large	~40-50%
Pituitary engorgement	Hyperemia of pituitary gland; convex superior margin	~50-60%
Venous distension sign	Engorgement of dural venous sinuses and cerebral veins	~75%
Decrease in ventricular size	Small ventricles compared to baseline; "slit ventricles"	Variable
Optic chiasm descent	Sagging of optic chiasm below plane of anterior clinoids	Variable

LUMBAR PUNCTURE (CPT 62270)¶

Indication: Confirm low CSF pressure (opening pressure <6 cm H2O diagnostic; may be normal in 20-30% of SIH); obtain CSF to rule out meningitis or other causes of meningeal enhancement; therapeutic in IIH (NOT therapeutic in SIH - do not drain CSF)

Timing: URGENT if diagnosis uncertain and need to differentiate from meningitis; ROUTINE for elective diagnosis; CAUTION: LP can worsen symptoms in SIH patients and is often deferred if MRI findings are classic

Volume Required: 1-3 mL only (minimal volume; do NOT perform large-volume LP in suspected SIH)

Study	Rationale	Target Finding	ED	HOSP	OPD	ICU
Opening pressure	Diagnostic criterion for intracranial hypotension; <6 cm H2O diagnostic but may be normal (0-6 cm H2O supports diagnosis)	<6 cm H2O (may be 0 or negative; normal in 20-30%)	URGENT	URGENT	ROUTINE	URGENT
Cell count (tubes 1 and 4) (CPT 89051)	Rule out meningitis or SAH; SIH may show mild pleocytosis (<5-50 WBC)	WBC <5 typical; mild elevation possible in SIH	URGENT	URGENT	ROUTINE	URGENT
Protein (CPT 84157)	Often mildly elevated in SIH (45-100 mg/dL) due to meningeal irritation; rule out infection	Normal 15-45 mg/dL; mildly elevated in SIH is expected	URGENT	URGENT	ROUTINE	URGENT
Glucose with serum glucose (CPT 82945)	Rule out infectious meningitis	Normal (>60% of serum glucose)	URGENT	URGENT	ROUTINE	URGENT
Gram stain and culture (CPT 87205, 87070)	Rule out bacterial meningitis if fever or meningismus present	No organisms	URGENT	URGENT	-	URGENT
RBC count (CPT 89051)	Rule out traumatic tap vs. xanthochromia from chronic SIH-related subdural collections	Document; xanthochromia may occur in SIH	URGENT	URGENT	ROUTINE	URGENT

Special Handling: Measure opening pressure with patient in lateral decubitus, legs extended, relaxed; use smallest gauge needle possible (22G or smaller) to minimize additional leak risk Contraindications: LP may worsen SIH symptoms; defer if MRI brain findings are classic for SIH; mass lesion; coagulopathy (INR >1.5, platelets <50,000); local infection at puncture site

3. TREATMENT¶

3A. Acute/Conservative Management¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
IV normal saline	IV	Volume resuscitation and symptom relief in acute SIH/PDPH	75-150 mL/hr :: IV :: continuous :: NS at 75-150 mL/hr; bolus 1L if dehydrated; maintain euvolemia	Heart failure, volume overload, renal failure	I/O, daily weights, electrolytes	STAT	STAT	-	STAT
Caffeine sodium benzoate IV	IV	Acute treatment of PDPH; cerebral vasoconstriction to counteract CSF hypotension	500 mg once :: IV :: once :: 500 mg IV infused over 1 hour; may repeat once in 4-6 hours; max 1000 mg/day	Cardiac arrhythmia, uncontrolled tachycardia, seizure disorder	Heart rate, blood pressure, arrhythmia	URGENT	URGENT	-	URGENT
Caffeine oral	PO	Mild SIH/PDPH; cerebral vasoconstriction	200 mg q6h :: PO :: q6h PRN :: 200-300 mg PO q6h (coffee ~100 mg/cup); max 900 mg/day; adjunct to other measures	Cardiac arrhythmia, severe anxiety, insomnia	Heart rate, sleep quality, anxiety	URGENT	ROUTINE	ROUTINE	-
Strict bed rest (Trendelenburg)	-	Reduce hydrostatic pressure across dural defect; facilitate seal	Flat or Trendelenburg position :: - :: continuous :: Strict bed rest in supine or slight Trendelenburg (10-15 degrees) for 24-48 hours initially; allow bathroom privileges only	DVT risk with prolonged immobility	DVT prophylaxis, skin integrity	STAT	STAT	-	STAT
Abdominal binder	-	Increase intra-abdominal and epidural venous pressure to tamponade leak	Apply snugly :: - :: continuous :: Apply abdominal binder continuously while upright; may improve symptoms by increasing epidural pressure	Abdominal surgery, respiratory compromise	Respiratory comfort, skin integrity	URGENT	ROUTINE	ROUTINE	-
Acetaminophen	PO	Headache symptom relief	1000 mg q6h :: PO :: q6h PRN :: 1000 mg PO q6h PRN headache; max 3000 mg/day	Hepatic disease, chronic alcohol use >3 drinks/day	LFTs if prolonged use	URGENT	ROUTINE	ROUTINE	-
Ibuprofen	PO	Headache and meningeal inflammation relief	400 mg q6h :: PO :: q6h PRN :: 400-600 mg PO q6h PRN; max 2400 mg/day; take with food	Renal disease, GI bleeding, anticoagulation, aspirin allergy	Renal function, GI symptoms	URGENT	ROUTINE	ROUTINE	-
Ondansetron	IV/PO	Nausea associated with orthostatic symptoms and SIH	4 mg q8h PRN :: IV :: q8h PRN :: 4-8 mg IV or PO q8h PRN nausea; max 24 mg/day	QT prolongation, severe hepatic impairment	QTc if repeated dosing	URGENT	ROUTINE	ROUTINE	-
Docusate sodium	PO	Prevent straining during bed rest which can worsen CSF leak	100 mg BID :: PO :: BID :: 100 mg PO BID; continue throughout bed rest period and until regular activity resumes	Intestinal obstruction	Bowel frequency	-	ROUTINE	ROUTINE	-
Enoxaparin	SC	DVT prophylaxis during prolonged bed rest in hospitalized SIH patients	40 mg daily :: SC :: daily :: 40 mg SC daily; begin within 24 hours of admission if on bed rest >48 hours; hold 12 hours before and after epidural blood patch	Active bleeding, HIT, severe renal impairment (CrCl <30: reduce to 30 mg daily), coagulopathy, within 12 hours of EBP	Platelet count q2-3 days; signs of bleeding; renal function	-	ROUTINE	-	ROUTINE

3B. Epidural Blood Patch (Primary Definitive Treatment)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Epidural blood patch - blind/non-targeted (CPT 62273)	Epidural	First-line definitive treatment for PDPH and SIH; seals dural defect with autologous blood clot	15-30 mL autologous blood :: Epidural :: once :: Inject 15-30 mL autologous blood into lumbar or thoracolumbar epidural space under fluoroscopy; patient lies flat 1-2 hours post-procedure; ~70-90% PDPH success rate; ~30-50% SIH success rate on first attempt	Active systemic infection/bacteremia, local skin infection, coagulopathy (INR >1.5, platelets <50K), patient refusal	Vital signs during and 1h post-procedure; neurologic exam; pain at injection site; radicular symptoms (transient acceptable)	URGENT	URGENT	ROUTINE	-
Epidural blood patch - targeted (CPT 62273)	Epidural	SIH after leak localization by CT myelography or MRI spine; targeted to level of leak	15-30 mL autologous blood :: Epidural :: once :: Inject 15-30 mL autologous blood at or near identified leak level under fluoroscopic or CT guidance; higher success rate for SIH when targeted; may require multi-level injection	Active systemic infection/bacteremia, local skin infection, coagulopathy (INR >1.5, platelets <50K), patient refusal	Vital signs during and 1h post-procedure; neurologic exam; radicular symptoms; headache improvement within 24-72 hours	-	URGENT	ROUTINE	-
Repeat epidural blood patch	Epidural	Persistent symptoms after initial EBP; may attempt 2-3 times before escalating	20-30 mL autologous blood :: Epidural :: once :: Repeat EBP 5-7 days after first attempt if symptoms persist; may use larger volume (up to 30 mL); consider targeted approach if not done initially	Active systemic infection/bacteremia, local skin infection, coagulopathy (INR >1.5, platelets <50K), patient refusal	Vital signs during and 1h post-procedure; neurologic exam; consider leak localization if second EBP fails	-	URGENT	ROUTINE	-

3C. Pharmacologic Adjuncts¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Theophylline	PO	Adjunctive treatment for SIH; increases CSF production via adenosine receptor antagonism	200 mg BID :: PO :: BID :: Start 200 mg PO BID; titrate to 300 mg BID based on serum levels; target serum level 10-15 mcg/mL; may take 1-2 weeks for effect	Seizure disorder, cardiac arrhythmia, active peptic ulcer, hepatic impairment	Theophylline level q2-4 weeks initially; heart rate; GI symptoms; drug interactions (CYP1A2)	-	ROUTINE	ROUTINE	-
Hydrocortisone	IV	Refractory SIH not responding to EBP; anti-inflammatory effect on meninges; may increase CSF production	200 mg daily :: IV :: daily :: 200 mg IV on day 1 then taper: 200 mg IV daily x 2d, 150 mg x 2d, 100 mg x 2d, then convert to oral; total course 7-14 days	Active untreated infection, uncontrolled diabetes	Blood glucose q6h, blood pressure, electrolytes	-	URGENT	-	URGENT
Prednisone (oral taper)	PO	Outpatient management of refractory SIH; meningeal inflammation	60 mg daily :: PO :: daily :: 60 mg PO daily x 5 days, then taper by 10 mg every 3-5 days over 3-4 weeks	Active untreated infection, uncontrolled diabetes, GI bleeding	Blood glucose, blood pressure, mood, GI symptoms	-	ROUTINE	ROUTINE	-
Gabapentin	PO	Neuropathic headache component; adjunctive pain management in SIH	300 mg qHS :: PO :: qHS then TID :: Start 300 mg PO qHS; titrate by 300 mg q3-5d; target 900-1800 mg/day divided TID; max 3600 mg/day	Severe renal impairment (adjust dose)	Sedation, dizziness, peripheral edema	-	ROUTINE	ROUTINE	-
Pregabalin	PO	Alternative to gabapentin for neuropathic pain component	75 mg BID :: PO :: BID :: Start 75 mg PO BID; increase to 150 mg BID after 1 week; max 300 mg BID	Severe renal impairment (adjust dose), angioedema history	Sedation, weight gain, peripheral edema	-	ROUTINE	ROUTINE	-

3D. Interventional/Refractory Treatment¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Epidural fibrin glue patch	Epidural	Refractory SIH after failed EBP (2-3 attempts); seals dural defect with fibrin sealant	Fibrin sealant at leak site :: Epidural :: once :: Inject fibrin glue (e.g., Tisseel) at identified leak site under fluoroscopic or CT guidance; may combine with blood patch; performed by anesthesia or interventional radiology	Active infection, known allergy to fibrin/bovine components, coagulopathy	Post-procedure neuro exam, headache assessment, vital signs; observe 2-4 hours post	-	URGENT	EXT	-
CT-guided percutaneous fibrin glue injection	Percutaneous	Precisely localized leak refractory to EBP; allows direct placement at dural defect	Fibrin sealant via CT-guided needle :: Percutaneous :: once :: CT-guided needle placement at leak site followed by fibrin glue injection; requires interventional radiology expertise	Active infection, coagulopathy, inability to identify leak site	Post-procedure neuro exam; imaging follow-up	-	EXT	EXT	-
Surgical dural repair	Surgical	Definitive treatment for identified dural tear or meningeal diverticulum refractory to all conservative and percutaneous therapies	Surgical exploration and primary dural repair :: - :: once :: Open or minimally invasive surgical repair of dural defect; may include muscle/fascia graft; requires neurosurgical expertise; hospitalization 3-7 days	Poor surgical candidate, unable to localize leak	Post-op neuro exam, wound care, headache assessment, CSF leak recurrence monitoring	-	ROUTINE	EXT	ROUTINE
CSF-venous fistula ligation/embolization	Surgical/Endovascular	Confirmed CSF-venous fistula on DSM; increasingly recognized cause of refractory SIH	Surgical ligation or transvenous embolization :: - :: once :: Surgical ligation of fistulous nerve root sleeve; or transvenous embolization of draining vein; requires specialized center	Unable to confirm fistula, coagulopathy for surgery	Post-procedure neuro exam; repeat imaging to confirm resolution	-	EXT	EXT	-
Continuous epidural saline infusion	Epidural	Bridge therapy while awaiting definitive treatment; refractory symptoms	NS at 20-50 mL/hr :: Epidural :: continuous :: Continuous epidural normal saline infusion at 20-50 mL/hr via epidural catheter; temporary measure for severe refractory symptoms	Epidural infection, coagulopathy	Catheter site infection, neurologic exam, headache response	-	EXT	-	EXT
Intrathecal saline infusion	Intrathecal	Severe refractory SIH as bridge to definitive repair; restores CSF volume temporarily	NS at 15-30 mL/hr :: Intrathecal :: continuous :: Intrathecal normal saline via lumbar drain at 15-30 mL/hr; temporary measure only; risk of infection increases with duration	Active infection, coagulopathy	Infection surveillance, neurologic exam, ICP monitoring	-	EXT	-	EXT

3E. Subdural Hematoma Management (Complication of SIH)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Observation with serial imaging	-	Small, asymptomatic subdural collections; most resolve after CSF leak treatment	Serial CT head q1-2 weeks :: - :: per protocol :: Most subdural hygromas/hematomas resolve after successful treatment of underlying CSF leak; avoid surgical evacuation if possible	None	Neuro checks, serial CT, symptom progression	URGENT	ROUTINE	ROUTINE	URGENT
Epidural blood patch (treat underlying cause)	Epidural	Subdural collections secondary to SIH; treating the leak often resolves the subdural	15-30 mL autologous blood :: Epidural :: once :: EBP should be performed BEFORE considering surgical evacuation; inject 15-30 mL autologous blood into epidural space under fluoroscopy; SDH from SIH often recurs after drainage if leak not addressed	Active systemic infection/bacteremia, local skin infection, coagulopathy (INR >1.5, platelets <50K), patient refusal	Vital signs during and 1h post-procedure; neurologic exam; serial CT for SDH	URGENT	URGENT	ROUTINE	-
Neurosurgical evacuation	Surgical	Large symptomatic SDH with mass effect or neurologic deterioration not responding to CSF leak treatment	Burr hole or craniotomy :: - :: once :: Surgical evacuation only if mass effect, midline shift >5 mm, or declining mental status AND CSF leak has been addressed; high recurrence if leak untreated	Poor surgical candidate	Post-op neuro checks, repeat CT, ICP monitoring	STAT	STAT	-	STAT

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU
Neurology consult for diagnosis confirmation and management of intracranial hypotension	URGENT	ROUTINE	ROUTINE	URGENT
Anesthesiology or pain medicine consult for epidural blood patch placement	URGENT	URGENT	ROUTINE	URGENT
Neuroradiology consult for CT myelography interpretation and leak localization	-	URGENT	ROUTINE	-
Interventional radiology consult for CT-guided fibrin glue injection or targeted epidural blood patch	-	ROUTINE	ROUTINE	-
Neurosurgery consult for surgical dural repair if refractory to blood patch and fibrin glue treatments	-	ROUTINE	ROUTINE	-
Neurosurgery consult for subdural hematoma evaluation if symptomatic mass effect develops	STAT	STAT	-	STAT
Headache specialist referral for chronic post-SIH headache or persistent symptoms despite leak resolution	-	-	ROUTINE	-
Genetics/rheumatology referral for connective tissue disorder evaluation if recurrent spontaneous CSF leaks	-	-	EXT	-
Physical therapy for gradual return to activity and deconditioning after prolonged bed rest	-	ROUTINE	ROUTINE	-

4B. Patient/Family Instructions¶

Recommendation	ED	HOSP	OPD	ICU
Remain flat or in Trendelenburg position as much as possible to reduce headache while awaiting definitive treatment (upright posture worsens symptoms)	ROUTINE	ROUTINE	ROUTINE	-
Increase oral fluid intake to at least 2-3 liters daily to support CSF production and hydration	ROUTINE	ROUTINE	ROUTINE	-
Increase caffeine intake (coffee, tea) to 300-500 mg/day as this constricts cerebral blood vessels and may reduce headache	ROUTINE	ROUTINE	ROUTINE	-
Avoid Valsalva maneuvers (straining, heavy lifting, coughing) which can worsen or re-open CSF leaks	ROUTINE	ROUTINE	ROUTINE	-
After epidural blood patch: lie flat for 1-2 hours post-procedure, then gradually increase activity over 24-48 hours; avoid heavy lifting for 2-4 weeks	-	ROUTINE	ROUTINE	-
Return to ED immediately if headache suddenly becomes the worst headache of life, new neurologic symptoms develop (weakness, numbness, vision changes, confusion), or fever occurs (may indicate subdural hematoma, meningitis, or abscess)	ROUTINE	ROUTINE	ROUTINE	-
Some patients have persistent headache after successful leak treatment; this typically improves over weeks to months	-	ROUTINE	ROUTINE	-
Follow up with neurology in 1-2 weeks after epidural blood patch to assess response and plan further workup if needed	-	ROUTINE	ROUTINE	-

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD	ICU
Stay well-hydrated (2-3 L daily) to support CSF production and overall recovery	ROUTINE	ROUTINE	ROUTINE	-
Gradual return to physical activity after symptom resolution; avoid strenuous exercise for 4-6 weeks after blood patch	-	ROUTINE	ROUTINE	-
Avoid excessive caffeine withdrawal if caffeine has been used therapeutically (taper gradually to prevent rebound headache)	-	ROUTINE	ROUTINE	-
Compression stockings during prolonged bed rest for DVT prevention; ambulate when tolerated	-	ROUTINE	-	-
If connective tissue disorder identified: avoid contact sports and activities with high risk of spinal trauma	-	-	ROUTINE	-
Inform future anesthesiologists of SIH history; use smallest gauge spinal needle if LP/spinal anesthesia required in future	-	ROUTINE	ROUTINE	-

═══════════════════════════════════════════════════════════════ SECTION B: REFERENCE (Expand as Needed) ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Migraine	Pulsating, unilateral; nausea/photophobia; NOT positional (no clear orthostatic pattern); prior history	Clinical history; no pachymeningeal enhancement on MRI; no orthostatic pattern
Post-lumbar puncture headache (iatrogenic)	Clear history of recent LP or spinal anesthesia within days; typically resolves spontaneously or with EBP	History of procedure; timing correlation; response to blood patch
Idiopathic intracranial hypertension (IIH)	Headache WORSE when lying down; papilledema; elevated opening pressure (>25 cm H2O); obesity	LP with elevated OP; MRI shows empty sella, optic nerve sheath distension (no pachymeningeal enhancement)
Cerebral venous sinus thrombosis (CVST)	Progressive headache; seizures; focal deficits; hypercoagulable state; papilledema	MRV or CT venography showing venous thrombosis
Meningitis (infectious)	Fever, neck stiffness, photophobia; meningeal enhancement may mimic SIH	CSF pleocytosis, low glucose, positive cultures; fever; systemic illness
Leptomeningeal carcinomatosis	Nodular (not smooth) meningeal enhancement; cranial neuropathies; known malignancy	MRI shows nodular enhancement (vs. smooth in SIH); CSF cytology positive
Chiari I malformation	Positional headache may overlap; but usually Valsalva-provoked; not clearly orthostatic	MRI sagittal showing tonsillar descent >5 mm below foramen magnum; no pachymeningeal enhancement
Colloid cyst of third ventricle	Positional headache (worse with certain head positions); intermittent hydrocephalus	MRI/CT showing colloid cyst in third ventricle; acute hydrocephalus
Subdural hematoma (primary)	Headache, confusion, focal deficits; history of trauma or anticoagulation	CT/MRI showing subdural collection without brain sagging or pachymeningeal enhancement
Medication overuse headache	Chronic daily headache; overuse of analgesics >15 days/month	Medication diary; no orthostatic pattern; no MRI enhancement
Postural orthostatic tachycardia syndrome (POTS)	Orthostatic symptoms (lightheadedness, palpitations); headache may be positional	Tilt table test; HR increase >30 bpm without significant BP drop; normal MRI brain
Tension-type headache	Bilateral, pressing, mild-moderate; no positional component	Clinical diagnosis; no MRI abnormalities

6. MONITORING PARAMETERS¶

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Headache severity (0-10 VAS) with positional assessment	Per assessment; daily inpatient; each visit outpatient	Improving trend; resolution of orthostatic component	Escalate to EBP if conservative measures fail; repeat EBP or advance to imaging/intervention	STAT	ROUTINE	ROUTINE	STAT
Neurologic examination (mental status, cranial nerves, motor, sensory)	Per assessment; daily inpatient	Normal; no new focal deficits	Urgent imaging if new deficits (concern for SDH, brain herniation)	STAT	ROUTINE	ROUTINE	STAT
Orthostatic vital signs	Each assessment in ED; daily inpatient	No significant orthostatic changes	Increase IV fluids; assess for concurrent volume depletion	STAT	ROUTINE	ROUTINE	STAT
CT head (for subdural collections)	After diagnosis; repeat if symptoms worsen or fail to improve	No new or enlarging subdural collections	Neurosurgical consultation for large or symptomatic SDH	URGENT	ROUTINE	ROUTINE	URGENT
MRI brain with gadolinium (follow-up)	4-8 weeks after treatment; earlier if symptoms recur	Resolution of pachymeningeal enhancement and brain sagging	Consider repeat EBP or advanced leak localization	-	ROUTINE	ROUTINE	-
Theophylline level (if on theophylline)	q2-4 weeks initially; then q3 months when stable	10-15 mcg/mL	Dose adjust; hold if toxic (>20 mcg/mL)	-	ROUTINE	ROUTINE	-
Blood glucose (if on steroids)	q6h while on IV steroids; daily on oral taper	<180 mg/dL	Insulin sliding scale or hypoglycemic agent adjustment	-	ROUTINE	ROUTINE	ROUTINE
Rebound intracranial hypertension monitoring	Daily during first week after successful CSF leak treatment; each outpatient visit for 3 months	No new headache worse when lying down; no papilledema	Fundoscopic exam; consider LP to measure OP; acetazolamide if confirmed rebound IH	-	ROUTINE	ROUTINE	-

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge from ED	Mild orthostatic headache responsive to oral analgesics and caffeine; able to tolerate PO; no red flags (new neurologic deficits, fever, worst headache of life); outpatient MRI and neurology follow-up within 1 week arranged
Admit to hospital (floor)	Severe orthostatic headache preventing ambulation or oral intake; need for IV hydration and caffeine; scheduled for epidural blood patch; new diagnosis of SIH requiring urgent MRI and workup; concern for subdural hematoma
Admit to hospital (observation)	Post-dural puncture headache not responding to conservative measures after 24-48 hours; awaiting epidural blood patch
Neurosurgery/ICU transfer	Large subdural hematoma with mass effect or neurologic deterioration; posterior fossa crowding from brain sagging with signs of brainstem compression
Discharge from hospital	Headache significantly improved (>50% reduction) after EBP or conservative treatment; tolerating oral medications; able to ambulate; close outpatient follow-up arranged within 1-2 weeks
Outpatient management	Mild symptoms manageable with oral analgesics and caffeine; able to maintain hydration; no red flags; MRI brain already obtained or scheduled; neurology follow-up within 1-2 weeks
Outpatient follow-up schedule	Post-EBP: 1-2 weeks; Refractory SIH: weekly until improved; After resolution: 3 months then annually for 1-2 years to monitor for recurrence

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
Orthostatic headache is hallmark of SIH	Expert consensus; diagnostic criterion	Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA 2006 PubMed: 16705110
MRI brain with gadolinium showing pachymeningeal enhancement is most sensitive diagnostic finding	Class II, Level B	Mokri B. Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks. Headache 2013 PubMed: 23808630
Epidural blood patch is first-line definitive treatment for PDPH	Class I, Level A	Boonmak P, Boonmak S. Epidural blood patching for preventing and treating post-dural puncture headache. Cochrane Database Syst Rev 2010 PubMed: 20091522
Epidural blood patch effective for SIH	Class II, Level B	Sencakova D et al. The efficacy of epidural blood patch in spontaneous CSF leaks. Neurology 2001 PubMed: 11723293
CT myelography is gold standard for CSF leak localization	Class II, Level B	Mokri B. Spontaneous cerebrospinal fluid leaks: from intracranial hypotension to cerebrospinal fluid hypovolemia. Mayo Clin Proc 1999 PubMed: 10560599
Caffeine provides short-term benefit for PDPH	Class II, Level B	Camann WR et al. Effects of oral caffeine on postdural puncture headache. Anesth Analg 1990 PubMed: 2405733
Conservative treatment (bed rest, hydration, caffeine) as initial approach	Expert consensus	Schievink WI. Spontaneous spinal cerebrospinal fluid leaks. Cephalalgia 2008 PubMed: 19037970
CSF opening pressure may be normal in 20-30% of SIH patients	Class III, Level B	Schievink WI et al. Diagnostic criteria for headache due to spontaneous intracranial hypotension. Headache 2011 PubMed: 21658029
Targeted EBP has higher success rate than blind EBP for SIH	Class III, Level B	Kranz PG et al. CT-guided epidural blood patching of directly observed or potential leak sites for the targeted treatment of spontaneous intracranial hypotension. AJNR Am J Neuroradiol 2011 PubMed: 21349964
Fibrin glue sealant effective for refractory CSF leaks	Class III, Level C	Schievink WI et al. Treatment of spontaneous intracranial hypotension with percutaneous placement of fibrin sealant. J Neurosurg 2004 PubMed: 15200130
Surgical repair for refractory dural defects	Class III, Level C	Schievink WI et al. Surgical treatment of spontaneous spinal cerebrospinal fluid leaks. J Neurosurg 1998 PubMed: 9452231
Brain sagging on MRI correlates with clinical severity	Class III, Level B	Savoiardo M et al. Spontaneous intracranial hypotension with deep brain swelling. Brain 2007 PubMed: 17535837
Connective tissue disorders (EDS, Marfan) predispose to SIH	Class III, Level B	Schievink WI et al. Connective tissue disorders with spontaneous spinal CSF leaks and intracranial hypotension. Neurosurgery 2004 PubMed: 14683542
Subdural hematomas complicate SIH and often resolve after leak treatment	Class III, Level B	De Noronha RJ et al. Subdural haematoma: a potentially serious consequence of spontaneous intracranial hypotension. J Neurol Neurosurg Psychiatry 2003 PubMed: 12754345
CSF-venous fistulas are an underrecognized cause of SIH	Class III, Level C	Schievink WI et al. A classification system of spontaneous spinal CSF leaks. Neurology 2016 PubMed: 27440149
Digital subtraction myelography is gold standard for CSF-venous fistula detection	Class III, Level C	Farb RI et al. Spontaneous intracranial hypotension: a systematic imaging approach for CSF leak localization and management. AJNR Am J Neuroradiol 2019 PubMed: 30923083
Theophylline may increase CSF production via adenosine receptor antagonism	Class III, Level C	Mokri B. Headaches caused by decreased intracranial pressure: diagnosis and management. Curr Opin Neurol 2003 PubMed: 12858068
Hydrocortisone/corticosteroids as adjunctive therapy for refractory SIH	Class III, Level C	Grimaldi D et al. Spontaneous low cerebrospinal pressure: a mini review. Neurol Sci 2004 PubMed: 15549523
ICHD-3 diagnostic criteria for headache attributed to low CSF pressure	Expert consensus	Headache Classification Committee of the International Headache Society. ICHD-3. Cephalalgia 2018 PubMed: 29368949
Intrathecal gadolinium MRI for slow leak detection	Class III, Level C	Akbar JJ et al. The role of MR myelography with intrathecal gadolinium in localization of spinal CSF leaks in patients with spontaneous intracranial hypotension. AJNR Am J Neuroradiol 2012 PubMed: 22173753
MR myelography for non-invasive leak screening	Class II, Level B	Wang SJ. Spontaneous intracranial hypotension. Continuum (Minneap Minn) 2021 PubMed: 34048402
Dynamic CT myelography for fast CSF leaks	Class III, Level C	Kranz PG et al. Imaging signs in spontaneous intracranial hypotension: prevalence and relationship to CSF pressure. AJNR Am J Neuroradiol 2016 PubMed: 26869465
Continuous epidural saline infusion as bridge therapy	Case series	Bai J et al. Continuous epidural saline infusion for treatment of refractory spontaneous intracranial hypotension. Pain Physician 2017

NOTES¶

SIH is often underdiagnosed; maintain high suspicion in any patient with new orthostatic headache
Classic triad: orthostatic headache, diffuse pachymeningeal enhancement on MRI, low CSF opening pressure (though OP may be normal in 20-30%)
MRI brain with gadolinium is the most important diagnostic test; do NOT rely on LP alone
PDPH typically self-resolves within 1-2 weeks; EBP indicated if symptoms persist beyond 24-48 hours or are severe
For SIH, blind EBP success rate is only 30-50% (vs. 70-90% for PDPH); targeted EBP after leak localization is preferred
CSF-venous fistulas are an increasingly recognized cause of SIH; require specialized imaging (digital subtraction myelography) for diagnosis
Subdural hematomas in SIH patients should be treated by addressing the underlying CSF leak first; surgical evacuation alone leads to high recurrence
LP in suspected SIH may worsen symptoms and should be deferred if MRI brain findings are classic; when performed, use smallest gauge needle and remove minimal volume
Connective tissue disorders (Ehlers-Danlos, Marfan) are risk factors; screen if recurrent or young patient
Rebound intracranial hypertension can occur after successful CSF leak treatment; monitor for new headache pattern (worse lying down)
Chronic SIH can lead to superficial siderosis from repeated microbleeding along the neuroaxis

CHANGE LOG¶

v1.1 (January 30, 2026) - Added ICU coverage across all applicable sections (labs, LP, imaging, acute treatment, monitoring, referrals) per S1 - Fixed cross-references in Section 3E: replaced "Per EBP protocol above", "Per EBP contraindications", and "Per EBP monitoring" with self-contained content per C1/R1 - Added PubMed citation links to all references in Section 8; corrected journal names for Savoiardo (Brain 2007), Schievink connective tissue (Neurosurgery 2004), Mokri theophylline (Curr Opin Neurol 2003), Grimaldi mini review (Neurol Sci 2004), and Kranz targeted EBP (AJNR 2011) per C3/R2 - Moved docusate sodium from Section 4C to Section 3A as proper medication row with structured dosing per R4/M5 - Added enoxaparin (DVT prophylaxis) to Section 3A with complete dosing and EBP timing precautions per R5/M6 - Fixed gabapentin dosing: single start dose (300 mg qHS) in structured field with titration in full instructions per R6/M2 - Fixed pregabalin dosing: single start dose (75 mg BID) in structured field with titration in full instructions per R7/M3 - Added rebound intracranial hypertension monitoring to Section 6 per R8 - Removed duplicate DVT prophylaxis entry from Section 4C (now covered by enoxaparin in 3A and compression stockings in 4C) per M6 - Updated version to 1.1 in frontmatter, VERSION line, and change log

v1.0 (January 30, 2026) - Initial template creation - Comprehensive diagnostic workup including MRI brain, MRI spine, CT myelography, cisternography, and digital subtraction myelography - Conservative management with IV fluids, caffeine, bed rest, and abdominal binder - Epidural blood patch protocol (blind and targeted) - Pharmacologic adjuncts: theophylline, hydrocortisone, gabapentin, pregabalin - Interventional options: fibrin glue, surgical dural repair, CSF-venous fistula treatment - Subdural hematoma management in SIH context - Lumbar puncture section with low-volume caution - CSF-venous fistula recognition and treatment - Connective tissue disorder screening guidance