A CSF (cerebrospinal fluid) headache, also known as a post-dural puncture headache, is a severe headache that can occur after a lumbar puncture or epidural injection. The headache is caused by leakage of cerebrospinal fluid (CSF) through the puncture site in the dura mater, which is the tough outer membrane covering the spinal cord and brain.
What are the symptoms of a CSF headache?
The main symptoms of a CSF headache include:
- Throbbing or pounding pain, usually focused around the front or back of the head
- Pain that worsens soon after sitting or standing up, and improves after lying down
- Nausea and vomiting
- Photophobia – increased sensitivity to light
- Neck pain or stiffness
The headache typically starts within 1-5 days after the lumbar puncture or epidural procedure, as the CSF leak develops. The pain is often described as the worst headache someone has ever experienced. It can be extremely debilitating.
What does the headache feel like?
People describe CSF headaches in various ways, but some common descriptions include:
- “My head feels like it is going to explode”
- “It feels like my brain is too big for my skull”
- “There is a pounding, pulsating pain deep inside my head”
- “It feels like someone is stabbing me in the head with an ice pick”
- “My head throbs when I sit up or stand”
The pain from a CSF leak headache is often focused in the back of the head or forehead. It is frequently described as a unilateral headache, meaning it occurs on one side of the head. The headache may feel worse when coughing, straining, or bending over.
What does the headache feel like when standing up?
A hallmark symptom of a CSF leak headache is that the pain intensifies with upright postures and improves upon lying down.
Many people describe a “splitting” or “exploding” feeling when they first stand up after sitting or lying down. The pain may reach peak intensity within seconds to minutes after sitting or standing.
- “As soon as I stood up, it felt like my head was going to split open. The pain was unbearable.”
- “When I tried to get out of bed, it felt like my brain was going to explode out of my skull. I had to lie back down immediately.”
- “When I sat up in bed, my head started pounding horribly within 30 seconds. It was a throbbing, pulsating pain.”
The headache may feel like a severe migraine that intensifies with any upright position. The pain can become so debilitating that the person can only lie down until it improves.
What makes the headache worse?
Activities that can make a CSF leak headache worse include:
- Sitting or standing up from lying down
- Bending over or straining
- Coughing, laughing, or sneezing
- Exercise or physical exertion
- Activities that increase abdominal pressure, like bowel movements
- Sudden head movements
- Bright lights, loud noises, or strong smells (due to photophobia and phonophobia)
Basically, anything that increases intracranial pressure tends to intensify the headache pain. The most consistent aggravating factor is going from a lying to upright posture.
What makes the headache better?
Lying down flat typically brings relief from a CSF leak headache. The headache may start improving within minutes to hours of lying down.
Other things reported to provide some relief include:
- Caffeine
- Hydration – drinking water
- Abdominal binder – to increase intra-abdominal pressure
- Pain medications like acetaminophen or NSAIDs
- Dark, quiet room
However, the most reliable way to obtain relief is through bed rest in a supine position. People may spend days lying flat in bed waiting for a CSF leak to heal and the headache to resolve.
What causes the positional nature of the headache?
The characteristic worsening with upright posture is due to the physics of CSF pressure in the skull.
In the lying down position, the CSF pressure throughout the skull remains relatively constant.
But when upright, gravity causes CSF to flow downward from the site of leakage near the base of the skull towards the spinal area. This leads to a reduction of CSF volume and pressure in the cranial vault.
The falling CSF pressure in the brain causes the pain receptors in the meninges to stretch and trigger the headache. When the person lies back down, the CSF returns to equalize the pressure in the skull, alleviating the headache.
How severe is the pain?
CSF leak headaches are notoriously painful. In fact, studies rank them among the most severe headache pain levels:
- Average pain score of 7-10 on 10-point scale
- Often described as “the worst headache of my life”
- Can be as severe as migraines or cluster headaches
- Rated higher pain levels than post-surgery, trauma, or migraine headaches in studies
- Significant impact on quality of life and ability to carry out daily activities
CSF leak headaches may be the most intensely painful recurrent headache syndrome. The pain can be incapacitating – leaving the person bedridden until the CSF leak seals and intracranial pressure normalizes.
When does the headache occur after a lumbar puncture?
If a CSF leak headache is going to develop after a lumbar puncture (LP), it typically starts within the first 48 hours.
- Within 1-2 days: 60-70% of post-LP headaches
- Within 3 days: 90% of post-LP headaches
- After 5 days: Very rare to start
So if a severe positional headache has not set in within 2-3 days after an LP, it is less likely to still appear. However, late onset headaches 5-7 days later can sometimes happen.
For epidural injections, onset is usually within 24-48 hours but can be delayed up to 5 days. Anyone undergoing these procedures should be alert for intense headache pain that worsens upright in the first few days afterward.
How long does the headache last?
The duration of a CSF leak headache can vary significantly:
- Average duration is 5 days
- Most resolve within 1 week
- 85% resolve within 6 weeks
- Can persist for many weeks in some cases
- Rarely, symptoms last for months
The headache should steadily improve as the puncture site seals and the CSF leak diminishes. However, the course is not always predictable. Persistent CSF leaks are possible and require further evaluation and treatment.
With proper management, most post-dural puncture headaches resolve on their own within a week or two. But they can be recurrent with subsequent procedures.
Conclusion
In summary, CSF leak headaches after lumbar punctures or epidurals are often described as the worst and most positional headaches someone can experience. The pain is pounding or explosive, especially when going from lying down to sitting or standing up. It may feel like the brain is too large for the skull or that the head will split open. Relief comes from lying flat. The headache usually starts within a few days and lasts less than a week on average. But prompt evaluation is key if the headache persists.
| CSF Headache Intensity | Pain Level (0-10 scale) |
|---|---|
| At rest lying down | 3-6 |
| Sitting/standing up | 8-10 |
| With activity | 9-10 |
| Action | Effect on CSF Headache Pain |
|---|---|
| Lying down | Improves |
| Sitting/standing up | Intensifies |
| Straining/coughing | Worsens |
| Intense activity | Significantly worsens |
Onset of CSF Headache After Procedure
| Time after LP/Epidural | Percent of Headaches Starting |
|---|---|
| Within 24 hours | 25% |
| 1-2 days | 60-70% |
| 3 days | 90% |
| After 5 days | Rare |
Duration of Post-Dural Puncture Headaches
| Duration | Percent of CSF Headaches |
|---|---|
| Less than 1 week | 50% |
| 1-2 weeks | 30% |
| 2-6 weeks | 15% |
| More than 6 weeks | Rare |