Low CSF pressure headache is divided by the International Headache Society into three categories: 1) postdural puncture headache, 2) CSF fistula headache, and 3) headache attributed to spontaneous low CSF pressure.1 Finding an optimal way to “seal” a CSF leak with an epidural blood patch is often elusive.2 The difficulty lies in finding the site of leak (often lower cervical or upper thoracic).3
We present four patients with low CSF pressure headaches that responded to a cervical but not a lumbar epidural blood patch.
Case reports.
Patient 1.
A 36-year-old woman developed orthostatic headaches 1 month after a motor vehicle accident. Brain CT and MRI were normal. CSF opening pressure was unobtainable. CT myelogram showed CSF leaks at C1 to C2 and C6 to T2.
The patient was transferred to us with a diagnosis of low CSF pressure headache secondary to a traumatic dural tear. Conservative treatment with bedrest, hydration, nonsteroidal anti-inflammatory drugs, caffeine, and theophylline failed.
Repeat lumbar puncture revealed an unobtainable opening pressure, and CT myelogram showed CSF leaks on the right at C6 to C7, bilateral leaks at T1 to T2 nerve roots, and a subdural collection at C3 to C4. A cervicothoracic junction (T1 to T2) epidural blood patch (10 mL) resulted in immediate headache improvement. Two months later, brain and cervical spine MRI showed no pachymeningeal enhancement. Two years later, she denied disabling or orthostatic headaches.
Patient 2.
A 50-year-old woman with episodic migraine without aura developed orthostatic headaches. She was treated with a lumbar epidural blood patch with 3 days of relief.
Brain MRI demonstrated diffuse pachymeningeal enhancement, sagging of the cerebral hemispheres, effacement of the suprasellar cistern, and low-lying cerebellar tonsils. Radionuclide cisternography demonstrated rapid CSF turnover; CSF opening pressure was 20 mm H20. A second lumbar epidural blood patch worked for 4 days. A cervical epidural blood patch at C7 to T1 resulted in complete headache relief, which is still present 1 year later.
Patient 3.
A 25-year-old man developed sudden occipital orthostatic headaches. IV caffeine produced no relief. A lumbar epidural blood patch produced relief for 3 days; two others failed. Three months later, brain MRI demonstrated diffuse pachymeningeal enhancement, effacement of the subarachnoid spaces at the foramen magnum and inferior frontal region, and sagging of the cerebellum and cerebral cortex. CT myelogram demonstrated contrast extravasation outlining the posterior spinal muscles from the suboccipital region to the C2–C3 level, more on the right, suggesting a dural tear; CSF opening pressure was 140 mm H20. A C5 to C6 cervical epidural blood patch produced complete headache relief, which is still present 5 years later.
Patient 4.
A 38-year-old woman developed sudden-onset orthostatic headaches. CSF opening pressure was 40 mm H20. MRI of the spine demonstrated low-lying cerebellar tonsils and a subdural fluid collection extending from the posterior fossa to the thoracic region. A lumbar epidural blood patch provided 2 days of relief.
A CT myelogram revealed contrast leakage from C2 to C3 to L2 to L3, maximal at C7 to T1. Repeat lumbar epidural blood patch produced transient headache relief for 1 day. Epidural blood patch at the cervicothoracic junction (T1 to T2) produced complete headache resolution. On 18-month follow-up, she denied orthostatic headaches and only had her typical migraines.
Discussion.
The most common cause of low CSF pressure headache is lumbar puncture. Some patients have spontaneous low CSF pressure headache, most often due to a cryptic CSF leak. Conservative treatment options include bed rest, abdominal binder, hydration, caffeine, theophylline, and corticosteroids. If conservative treatment fails, lumbar epidural blood patching is often the next option. Epidural blood patches produce headache relief by immediately compressing the dural sac, raising intrathecal pressure and forming a seal at the site of the dural hole.4 Lumbar epidural blood patches are not as effective in cryptic tears as the site of leak is often cervical or thoracic.
Cervical epidural blood patches are more commonly used by anesthesiologists than by headache experts.5 Their risk includes compression of the spinal cord and nerve roots, chemical meningitis, intrathecal injection of blood,6 and neck stiffness. Less blood is injected into cervical than lumbar epidural patches.7
One of our patients had a history of trauma; the other three had spontaneous low CSF pressure headaches. All four responded dramatically to cervical epidural blood patches after failed lumbar epidural blood patches, suggesting that even without a specific site of CSF leakage, cervical epidural blood patches may be useful after failed lumbar epidural blood patches.
There are few reported cases of successful treatment of low CSF pressure headaches with targeted cervical epidural blood patches. None of our patients needed a second cervical epidural blood patch to attain headache relief.
Footnotes
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Disclosure: The authors report no conflicts of interest.
Received November 21, 2004. Accepted in final form June 16, 2005.
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