A positional headache is one that occurs when sitting or standing and improves when lying down. Bending, sneezing, lifting, and straining may also cause it. It often results from a leak of cerebrospinal fluid (CSF) and symptoms usually localize to the back of the head.
Positional headaches are also known as orthostatic, postural, and low pressure headaches.
As well as leaks of CSF, other conditions can cause positional headaches. These include conditions that affect the connective tissues, bones, and nervous system.
This article covers the symptoms and causes of positional headaches, as well as the treatment options available.
Most positional headaches cause pain that is worse when a person is upright and goes away after they lie flat for around 20–30 minutes.
Some people with positional headaches may wake up in the morning with a mild headache that gets worse throughout the day.
It is also not unusual for the positional nature of headaches to go away or become weaker over time.
Positional headaches tend to cause pain in the back of the head, though they can also affect the front of the head, just one side of it, or the entire head. People describe the pain associated with positional headaches as:
Certain actions and activities can make headache symptoms worse. These include:
- coughing or sneezing
- strenuous exercises
- sexual activities
- bending over
- straining during a bowel movement
This section covers some specific causes of positional headaches.
The cause of a positional headache is often low spinal fluid pressure inside the head, which occurs in a condition called intracranial hypotension. Intracranial hypotension generally relates to a loss or imbalance of CSF.
CSF cushions the brain and spinal cord within special membranes called meninges. These meninges prevent the brain and spinal cord from coming into contact with boney structures during movement.
When something damages the meninges, it can allow CSF to leak into the body, lowering fluid volume and pressure.
This change in pressure can drop the position of the brain. This means that the brain is more likely to come into contact with pain-sensitive structures in the head or spine.
Most positional headaches develop while a person is sitting or standing upright. This is because a lot of circulating CSF surrounds the spinal cord, and when someone with reduced CSF levels is standing or sitting, their CSF levels reduce even further. This increases the risk of positional headache.
A doctor will normally rule out a CSF leak before looking into other potential causes.
Positional headaches can sometimes result from structural problems or conditions that impact parts of the neck, rather than head itself.
For example, the headache could develop due to problems with the:
- intervertebral discs
- connective tissues
- nerves and blood vessels
- facet joints
- skeletal muscles
Postural orthostatic tachycardia syndrome
This is a condition involving dysfunction of the autonomic nervous system, which regulates important processes such as heart function and fluid balance.
Postural orthostatic tachycardia syndrome (POTS) causes rapid heartbeat and blood pressure changes when the person is standing. It may develop after someone with a CSF leak or other debilitating condition has needed to remain bedridden for a long period of time, such as during a prolonged hospitalization.
Anyone at any age can develop POTS, but it mainly affects women
In fact, it has been diagnosed in individuals following infection with COVID-19. People who have long COVID (sometimes called long haulers) may develop POTS. It may make individuals unable to exercise because the activity brings on fainting spells or dizziness.
A doctor will typically rule out a CSF leak before testing for other conditions. They will do this by asking questions about the person’s symptoms, reviewing their medical history, and ordering diagnostic tests.
Some tests that doctors can use to detect CSF leaks include MRI scans and CT myelography scans.
MRI scans use strong magnetic fields to create an image that reveals typical CSF leak patterns in around 80% of cases. Conventional MRI scans are not very sensitive and do not always provide the answer. Newer functional MRI techniques, such as upright positioning and 3D weighted imaging, are extremely sensitive and permit doctors to identify the precise cause of the problem that was previously undetected.
CT myelography scans are performed less frequently due to the advances in MRI scanning. In this procedure, a contrast agent is injected directly into the spinal canal via lumbar puncture to enhance the visualization damage, abnormalities, or leaks.
To rule out POTS, a doctor may also order a Trendelenburg test. This involves the person lying flat on an exam table that alternates between being horizontal and lowering the head. During this test, a doctor will monitor the person’s heart rate and blood pressure.
The best treatment option for positional headaches depends on the underlying cause.
Treatments for CSF leaks vary based on their severity and the location of the leak.
Mild-to-moderate CSF cases may respond to a range of lifestyle remedies, including:
- getting bed rest or staying horizontal
- drinking plenty of fluids
- undergoing intravenous (IV) fluid therapy
- avoiding strenuous activities, such as heavy lifting
- limiting minor straining activities, if possible, such as coughing or sneezing
- drinking caffeine or undergoing IV caffeine therapy
- trying ginger products (for nausea)
- eating a healthful, balanced diet
- practicing mind-body techniques, such as meditation or yoga
- trying acupuncture
- using an abdominal binder for compression
However, some mild-to-moderate CSF symptoms may get better without any treatment.
Certain medications can also help manage the symptoms of CSF leaks.
However, researchers are yet to prove the effectiveness of most of these. In fact, some of these medications may carry serious health risks, including disability.
Some medications for CSF leak symptoms include:
- antinausea medications such as ondansetron
- nonopiate pain medications
Epidural blood patch
People with CSF leaks may also need to undergo an epidural blood patch (EBP). This is a procedure wherein a doctor injects 10–100 milliliters of a person’s own blood into the epidural space in their spinal canal.
The blood will form a clot which creates a patch on the outer layer of the meninges, which can effectively stop CSF loss.
A doctor will perform an EBP procedure at the location of a leak, or in the middle or lower parts of the spine if they do not know the exact location of the leak.
Health professionals do not know exactly why this procedure seems to help manage CSF leaks. However, at the very least, it seems to help relieve symptoms and confirm the diagnosis.
People should try to avoid strenuous activities or bending over for 4–6 weeks after undergoing an EBP procedure.
Blood patching usually brings instant relief of symptoms, but its effect can wear off, causing the need for multiple procedures.
In severe or chronic cases, or when the precise location of the leak is known, doctors may perform surgery. The type and extent of the surgery depends on individual factors.
Several different types of surgery may be necessary to remove or repair structural abnormalities or abnormal growths, such as tumors, malformations, or cysts.
There is no cure for POTS. However, increasing blood volume and helping regulate circulatory conditions can help.
Some medications and lifestyle changes that may assist in this include:
- increasing fluid intake
- exercising regularly at a gradual pace
- increasing salt intake
- taking fludrocortisone, if on a high salt diet
- taking low dose midodrine
- taking beta-blockers
It is difficult to reduce the risk of positional headaches, apart from by practicing good safety, sticking to healthful habits, and addressing any underlying health conditions.
There are several different factors that can increase the risk of developing a CSF leak, which is a common cause of positional headaches. These include:
- sneezing or coughing too hard or frequently
- straining too hard during exercise or activities
- roller-coaster rides and other jerky, position-changing activities
- medical procedures, such as lumbar punctures
- fistulas, or abnormal pockets of tissue
- certain genetic or hereditary conditions, such as Chiari malformations and polycystic kidney disease
- tumors or cysts in the head, neck, or spine
For the conditions that cause positional headaches, receiving an early diagnosis and prompt treatment usually reduces the risk of serious complications.
See a doctor as soon as possible or seek emergency care if any warning signs of CSF leaks or POTS accompany positional headaches.
Some warning signs of a CSF leak include:
- nausea and vomiting
- neck pain or stiffness
- sensitivity to light and sound
- balance problems
- ringing in the ears, muffled hearing, or hearing loss
- pain between the shoulder blades
- brain fog
- dizziness or vertigo
- facial pain or numbness
- pain or numbness in the arms or below them
- double vision or blurred vision
- chest or back pain
- changes to how things taste
- nipple discharge
- racing heartbeat or rapid changes in blood pressure when changing position
- fainting when standing up
Positional headaches usually occur while a person is standing or sitting upright and improve when they lie down. Only a few conditions can cause them, most notably CSF leaks and POTS.
Some CSF leaks resolve without treatment, whereas others require lifestyle changes, medications, EBP procedures, or surgical repairs.
Treatments for most CSF leaks tend to be successful, but some people may continue to have symptoms and persistent disability after several treatments.
There is no cure for POTS, but people can manage it by making lifestyle changes and taking medication to control blood pressure and volume.
To reduce the risk of complications, speak to a doctor about any unexplained, chronic, or severe headaches, especially those that change with position.