Orthostatic headaches


Orthostatic headaches (or postural, positional headaches) are headaches that usually occur when sitting or standing and go away quite soon after lying down.

Loss of cerebrospinal fluid (CSF) is a common cause of positional headaches, but there are several others, including those associated with connective tissue, bones, and the nervous system.


A positional headache often occurs when a person is standing.

Most positional headaches cause pain that gets worse when a person is standing and goes away when lying down for about 30 minutes.

Some people with postural postural headaches may wake up in the morning with a mild headache that will get worse throughout the day.

It’s also not uncommon for headaches to go away or get weaker over time.

Positional headaches tend to cause pain in the back of the head, although they can also affect the front of the head, only one side of it, or the entire head.

Certain activities can make headache symptoms worse, such as:

  • coughing or sneezing
  • moderate to intense exercise
  • sexual activities
  • leaning position


There are some specific causes of positional headaches.

Loss of cerebrospinal fluid

The cause of postural orthostatic headaches is often low pressure of the cerebrospinal fluid (CSF) inside the head, which occurs with intracranial hypotension. Intracranial hypotension is usually related to loss or imbalance of CSF.

CSF cushions the brain and spinal cord through special membranes called meninges. These meninges prevent the brain and spinal cord from coming into contact with bone structures during movement.

When the meninges are damaged the meninges, this allows CSF to infiltrate the body, reducing the volume and pressure of the fluid.

This change in pressure can lower the position of the brain. This means that the brain is more likely to come into contact with pain-sensitive structures in the head or spine.

Most orthostatic postural headaches develop when a person is sitting or standing. When a person with low CSF levels is standing or sitting, their levels drop even more, which increases the risk of headaches.

A doctor will normally rule out a CSF leak before looking for other causes.

Cerebrospinal fluid (CSF; white arrow). The most common symptom suggestive of a CSF leak in the spine is an orthostatic postural headache, which worsens in the upright position and improves in the horizontal position.

Cervicogenic headache

Orthostatic postural headaches can sometimes result from structural problems that affect parts of the neck, rather than the head itself.

For example, the headache could develop due to problems related to:

  • intervertebral discs
  • connective tissue
  • nerves and blood vessels
  • joints
  • skeletal muscles

Postural orthostatic tachycardia syndrome

It is a disease involving dysfunction of the autonomic nervous system, which regulates important functions such as heart function and water balance.

Postural orthostatic tachycardia syndrome causes rapid changes in heart rate and blood pressure when the person is standing. 

It can develop after a person with a loss of CSF or other debilitating condition has to lie down for a long time, for example due to hospitalization.


A doctor will usually rule out a loss of CSF before finding other conditions, asking about the patient’s symptoms, reviewing their medical history, and ordering diagnostic tests (magnetic resonance imaging test, CT myelography scan. ).

MRI scans use strong magnetic fields to create an image that reveals typical CSF losses in about 80% of cases. CT myelography scanners, on the other hand, use special X-rays and a dye to create detailed images that can reveal damage, abnormalities, or loss.

To rule out tachycardia syndrome, a doctor may also order the Trendelenburg test. This test involves asking a person lying flat on an examination table to alternate a horizontal position and lower their head. During this test, a doctor will monitor the person’s heart rate and blood pressure.


The best treatment option for orthostatic postural headache depends on the underlying cause.

Treatments for CSF losses vary depending on their severity and the location of the loss.

Here are some examples of lifestyle remedies:

  • rest or stay in a horizontal position
  • to drink a lot of water
  • avoiding strenuous activities, such as heavy lifting
  • if possible avoid coughing or sneezing
  • taking caffeinated drinks or taking intravenous caffeine therapy
  • trying products containing ginger (for nausea)
  • eat a healthy and balanced diet
  • practice meditation or yoga
  • try acupuncture
  • using abdominal binder for compression

However, some mild to moderate CSF symptoms may improve without treatment.


Certain medications can also help manage the symptoms of CSF loss.

However, researchers have yet to prove the effectiveness of most of them. In fact, some of these drugs can cause serious health risks, including disability.

Some medications for the symptoms of CSF loss include:

  • theophylline
  • nausea medications
  • non-opioid pain relievers

Epidural blood patch

People with CSF leaks may also need to have an epidural blood  patch . This is a procedure in which a doctor injects 10 to 100 milliliters of a person’s own blood into the epidural space of the spinal canal.

C treatment appears to help relieve symptoms and confirm the diagnosis.

People should try to avoid strenuous activities or bending over for 4-6 weeks after undergoing this treatment.


In severe or chronic cases, or when the precise location of the loss is known, doctors may perform surgery. The type and extent of surgery depend on individual factors.

Several different types of surgery may be needed to remove or repair structural abnormalities or abnormal growths, such as tumors, deformities, or cysts.

Symptom management

There is no cure for positional headaches. However, certain medications and lifestyle changes can help:

  • increased water intake;
  • exercise regularly at a gradual pace;
  • increased salt intake;
  • take fludrocortisone, if you are on a high salt diet;
  • take beta blockers.

Risk factors

There are several factors that can increase the risk of developing CSF loss and that are a common cause of positional headaches. They include:

  • too hard or frequent sneezing or coughing;
  • too much tension during exercise or activities;
  • medical interventions, such as lumbar punctures;
  • fistulas or abnormal pockets of tissue;
  • certain genetic or hereditary diseases, such as Chiari malformations and polycystic kidney disease;
  • tumors or cysts of the head, neck or spine.

When to consult a doctor

Receiving early diagnosis and prompt treatment usually reduces the risk of serious complications.

See a doctor as soon as possible or seek emergency care if you have certain warning signs of CSF loss:

  • nausea and vomiting
  • neck pain or stiffness
  • sensitivity to light and sound
  • balance problems
  • ringing in the ears or hearing loss
  • pain between the shoulder blades
  • dizziness or vertigo
  • pain or numbness in the face or arms
  • double vision or blurred vision
  • chest or back pain
  • tired
  • changes in the taste of food
  • fast heart rate or rapid changes in blood pressure when changing position
  • fainting or dizziness when standing up