Postural headache due to spontaneous intracranial hypotension in an adolescent

Case Report: We report on a 15-year-old boy presenting with postural headache starting three months before his admission. The headache started in upright position and resolved completely when lying down. No concomitant symptoms were described. Two days before the headache started there was an episode with sudden lower back pain radiating to the thoracic spine.

Diagnostics: Initial cranial magnetic resonance imaging (MRI) was within normal limits. A control 6 weeks later showed a tonsillar herniation into the foramen magnum of 11 mm, as well as narrow ventricles and enlarged cerebral veins. MRI of the spine was – apart from a narrow spinal canal – within normal limits. Constructive interference in steady state (CISS) sequence showed an enlarged subarachnoid space around the first sacral root. Due to the clinical presentation, we suspected intracranial hypotension and performed a CT myelography. At the lumbar and thoracic level we found extensive cerebrospinal fluid (CSF) leakage to the epidural space.

Therapy: We applied epidural blood patches at the lumbar level at six spots covering the whole circumference of the spinal dural sac. After a few days of bed rest, the headache completely resolved also in upright position.

Discussion: Postural headache caused by spontaneous intracranial hypotension, which is due to spinal CSF leakage, is well-known in adults. Concerning the few case reports on pediatric patients, however, the development of a tonsillar herniation and multiple CSF leaks have not been described so far. After ineffective conservative pain therapy, only epidural blood patching proved to be effective.

Conclusion: Also for pediatric patients suffering from postural headache without history of lumbar puncture, intracranial hypotension due to spontaneous CSF leakage should be considered-especially in the presence of a concomitant tonsillar herniation.