Orthostatic postural headaches


Postural orthostatic headaches are headaches that usually occur while sitting or standing and disappear fairly soon after lying down.

The cause of postural orthostatic headaches is not known. It may be due to changes in blood pressure when changing position. This change in blood pressure causes the brain to send signals to the head which results in pain.

CSF leaks are often the cause of positional headaches, but there are several other causes, including those associated with connective tissues, 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 stands up and improves when they lie down for about 30 minutes.

Some people with orthostatic postural headaches may wake up with a mild headache that will worsen throughout the day.

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

Positional headaches tend to affect the back of the head, although they can also affect the front of the head, just one side of it, or the whole head.

Certain activities can make headache symptoms worse, such as:

  • cough or sneeze
  • moderate to intense intensity exercises
  • sexual activities
  • leaning position


There are some specific causes of positional headaches.

Loss of cerebrospinal fluid

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

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

When the meninges are damaged, they allow cerebral spinal fluid to seep into the body, reducing fluid volume and pressure.

This change in pressure can lower the position of the brain. This implies 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 who has low levels of CSF is standing or sitting, their levels drop even further, increasing the risk of headaches.

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

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 tissues
  • 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. 

Postural hypotension may develop after a person with CSF loss or another disabling condition has to lie down for a long time, for instance due to hospitalization.


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

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

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


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

Treatments for CSF leaks vary depending on their severity and the location of the leak.

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
  • avoid coughing or sneezing if possible
  • drink caffeinated beverages or undergo intravenous caffeine therapy
  • try products containing ginger (for nausea)
  • have a healthy and balanced diet
  • practicing meditation or yoga
  • try acupuncture
  • using an abdominal binder for compression

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


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

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

Some medications for CSF leak symptoms include:

  • theophylline
  • anti-nausea medications
  • non-opioid analgesics

Epidural blood patch

People with CSF leaks may also need 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 seems 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 depends on individual factors.

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

Symptom management

There is no cure for positional headaches. However, certain medications and lifestyle changes may 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 are a common cause of positional headaches. They include:

  • too hard or frequent sneezing or coughing;
  • too much tension during exercise or activities;
  • medical procedures, 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 an early diagnosis and prompt treatment generally 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 in the arms
  • double vision or blurred vision
  • chest or back pain
  • fatigue
  • changes in the taste of food
  • rapid heartbeat or rapid changes in blood pressure when changing position
  • fainting or dizziness when standing up