Chronic Headache Tragically Missed Cause – Intracranial Hypotension – And Poor Imaging Issues

New cases series of patient twith chronic headache that oft went thru a litany of doctors without success with a clearly treatable disease. Each gave a history of  headache on arising and relieved by lying down that was discounted because intracranial hypotension is so rare.

The commonly missed diagnosis of intracranial hypotension
Interdisciplinary Neurosurgery:  Advanced Techniques and Case Management
(2016) in press
Ashlee N. Ruggeri-McKinley , RN, Brock

  • mention how headaches can be misdiagnosed for decades and people subjected to “unnecessary testing and treatment”.
  • Physical exams are negative so a detailed history of pain getting up and relieved by being lying down becomes imperative
  • Injecting blood into spinal fluid as a patch can cure the disorder.

One case stands out to me:

  • 28 year woman with daily subacute severe throbbing and stabbing headaches for 9 months
  • Occipital pains at start then going to forehead as well
  • started at morning or midday and progressed in severity
  • she noted that pains are worse on standing and so spent most of her time lying down.
  • Had migraine features which confused things – photophobia (light sensitivity), and nausea
  • also had interscapular pain, tinnitus, diminished hearing,  and urge incontinence (spastic bladder) which could be dismissed as Fibromyalgia features
  • Interestingly, this case did note improvement with caffeine which is typical for intracranial hypotension
  • MRI (I presume dye enhanced) showed brain and spinal cord changes.
  • Blood patch resolved issues

Comment – what I fearsubjects with superimposed migraines  gets this disordermay just presetn with a chronic headache all the time and issues with standing are less obvious. I also fear that headache subjects are getting non-dye enhanced MRI of only the brain which would also miss the spinal features.  Gadolinium-enhanced axial T1-weighted image is needed to demonstrate the  “diffuse pachymeningeal (dural) enhancement”. Typically, neurologists order dye enhancement just in cases of suspected Multiple Sclerosis.  In:

AJR Am J Roentgenol. 2013 Feb;200(2):400-7. doi: 10.2214/AJR.12.8611.
Intracranial hypotension: improved MRI detection with diagnostic intracranial angles.Shah LM(1), McLean LA, Heilbrun ME, Salzman KL.

They state “The classic MRI features of intracranial hypotension can be variable and subjective.”

Lu, Yu-Feng CHeng1 CHeng-HsIen, and WeI-CHe LIn.
Application of Cine Phase Contrast MRI in Spontaneous Intracranial Hypotension Before  and After Treatment.”
J Radiol Sci 2014:39: 67-75

They referenced 3 articles that state:
“However, some studies have reported that up to 20% of patients with clinically apparent SIH (Spontaneous intracranial hypotension) lack any abnormal cranial MRI findings

I bet those statistics would be even higher in non-dye enhanced cases.

Needless to say I have no faith in MRI imaging here, where the ?lazy way out tends to be in the non-dye enhanced imaging and there is an excessive confidence that MRI imaging will give all the answers.

Any comments?

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