Ringing in the Ears and Pain in the Head

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Abstract The case presented in this chapter illustrates the classic clinical features of a low-pressure headache. The pathophysiology results from the loss of cerebrospinal fluid (CSF). This causes sagging of the brain, stretching of the bridging veins, and venodilation. The clinical history is of a headache that is worse in the upright position and remits when the patient is supine. Due to the connection of the perilymphatic fluid and CSF, postural tinnitus is a frequent symptom. Risk factors for low-pressure headache include those that are patient-specific: female sex, low body mass index, prior history of a low-pressure headache, and an underlying headache disorder. Most of these headaches follow dural puncture with a lumbar puncture or spinal or epidural anesthetic. Operator-specific factors that decrease the risk of a post dural puncture headache include greater operator experience and the use of a smaller-gauge, non-cutting (pencil-point) lumbar puncture needle. The best treatment for low-pressure headache is an epidural blood patch, with resolution in more than 90% of low-pressure headaches.

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