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>> Spinal CSF Leak Symptoms

The most common and classic symptom suggestive of a spinal CSF leak is a positional headache: a headache that is worse when upright and improved when positioned horizontally. It is not unusual for the headache to become less positional over time or for the positional aspect to resolve entirely. Occasionally, the headache is never positional and rarely, a reverse pattern of worse headache when recumbent has been reported. Note that not all patients with a positional headache have a spinal CSF leak and not all headaches related to spinal CSF leaks are positional. The headache is often located at the back of the head but can be frontal, bitemporal or all over the head. Headache severity varies enormously from mild to severe and may not correlate well with findings on imaging. Many patients are quite disabled by their inability to be functional while upright.
There are a number of non-headache signs and symptoms.

Recognition of the headache pattern and other symptoms is important in leading physicians to suspect the diagnosis of intracranial hypotension secondary to a spinal CSF leak.


Common symptoms:
Headache that is worse when upright and better when horizontal (but other patterns do occur)
Nausea and vomiting
Neck pain or stiffness
Change in hearing (muffled, underwater, tinnitus)
Sense of imbalance
Photophobia (sensitivity to light)
Phonophobia (sensitivity to sound)
Interscapular (between shoulder blades) pain
Pain or numbness of arms
Changes in cognition (“brain fog”)
Dizziness or vertigo

Less common symptoms:
Visual changes (blurring, double vision, visual field defects)
Facial numbness or pain
Changes in taste
Pain or numbness at various nerve root levels below the arms
Galactorrhea (fluid discharge from nipples)

Rare signs or complications:
Parkinsonism, other movement disorders
Ataxia (unsteady gait)
Stupor / coma
Cerebral venous thrombosis
Reversible cerebral vasoconstriction
Stroke (hemorrhagic or ischemic)

Key Points:
• Not all patients with a positional headache have a spinal CSF leak
• Headache may be trivial or absent with other signs and symptoms being more prominent
• The positional aspect of headache often lessens with time and may be absent from the onset
• The severity of symptoms and associated disability is often under-appreciated