Woman With Severe Headache

A 42-year-old woman presented to the emergency department with a 2-day history of severe postural headache. It was gradual onset, diffuse, and consistently relieved when she lay down and provoked when she sat up. She had associated vomiting and a 3-day history of mild low back pain that started after lifting a cooler into her car. She had no associated vision changes, numbness, or weakness. Her neurologic examination result was unremarkable. Noncontrast computed tomography of the head was nondiagnostic.

Diagnosis

Traumatic dural tear with cerebrospinal fluid leak and intracranial hypotension . Magnetic resonance imaging (MRI) of the thoracic and lumbar spine demonstrated extensive extra-axial fluid collections within the spinal canal ( Figures 1 and 2 ). Contrast-enhanced MRI of the brain revealed enhancement of the dura and prominence of the pituitary gland ( Figure 3 ), consistent with intracranial hypotension. The patient was treated with an epidural blood patch at the fourth to fifth lumbar interspace, which resolved her headache.