Positional headaches: Symptoms, causes, and treatment (2023)

A positional headache is a type of headache that usually occurs when sitting or standing up and goes away fairly shortly after lying down. Positional headaches are also known as orthostatic, postural, and low pressure headaches.

Leaks of cerebrospinal fluid (CSF) are often the cause of positional headaches, but several other conditions can cause them. These include conditions that affect the connective tissues, bones, and nervous system.

This article covers the symptoms and causes of positional headaches, as well as the treatment options available.

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Most positional headaches cause pain that is worse when a person is upright and goes away after they lie flat for around 20–30 minutes.

Some people with positional headaches may wake up in the morning with a mild headache that gets worse throughout the day.

It is also not unusual for the positional nature of headaches to go away or become weaker over time.

Positional headaches tend to cause pain in the back of the head, though they can also affect the front of the head, just one side of it, or the entire head. People describe the pain associated with positional headaches as:

  • severe
  • pressure-like
  • throbbing
  • pounding
  • stabbing
  • aching

Certain actions and activities can make headache symptoms worse. These include:

  • coughing or sneezing
  • strenuous exercises
  • sexual activities
  • bending over
  • lifting
  • reaching
  • straining during a bowel movement

Causes

(Video) The Mystery Headache: Migraine, Positional Headache, Spinal Fluid Leak?

This section covers some specific causes of positional headaches.

CSF leak

The cause of a positional headache is often low spinal fluid pressure inside the head, which occurs in a condition called intracranial hypotension. Intracranial hypotension generally relates to a loss or imbalance of CSF.

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

When something damages the meninges, it can allow CSF to leak into the body, lowering fluid volume and pressure.

This change in pressure can drop 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 positional headaches develop while a person is sitting or standing upright. This is because a lot of circulating CSF surrounds the spinal cord, and when someone with reduced CSF levels is standing or sitting, their CSF levels reduce even further. This increases the risk of positional headache.

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

Cervicogenic headaches

Positional headaches can sometimes result from structural problems or conditions that impact parts of the neck, rather than head itself.

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

  • intervertebral discs
  • connective tissues
  • nerves and blood vessels
  • facet joints
  • skeletal muscles

Postural orthostatic tachycardia syndrome

This is a condition involving dysfunction of the autonomic nervous system, which regulates important processes such as heart function and fluid balance.

Postural orthostatic tachycardia syndrome (POTS) causes rapid heartbeat and blood pressure changes when the person is standing. It may develop after someone with a CSF leak or other debilitating condition has needed to remain lying down for a long period of time, such as due to hospitalization.

Learn more about POTS here.

A doctor will typically rule out a CSF leak before testing for other conditions. They will do this by asking questions about the person’s symptoms, reviewing their medical history, and ordering diagnostic tests.

Some tests that doctors can use to detect CSF leaks include MRI scans and CT myelography scans.

MRI scans use strong magnetic fields to create an image that reveals typical CSF leak patterns in around 80% of cases. CT myelography scans, meanwhile, use special X-rays and contrasting dye to create detailed images that can reveal damage, abnormalities, or leaks.

To rule out POTS, a doctor may also order a Trendelenburg test. This involves the person lying flat on an exam table that alternates between being horizontal and lowering the head. During this test, a doctor will monitor the person’s heart rate and blood pressure.

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The best treatment option for positional headaches depends on the underlying cause.

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

Mild-to-moderate CSF cases may respond to a range of lifestyle remedies, including:

  • getting bed rest or staying horizontal
  • drinking plenty of fluids
  • undergoing intravenous (IV) fluid therapy
  • avoiding strenuous activities, such as heavy lifting
  • limiting minor straining activities, if possible, such as coughing or sneezing
  • drinking caffeine or undergoing IV caffeine therapy
  • trying ginger products (for nausea)
  • eating a healthful, balanced diet
  • practicing mind-body techniques, such as meditation or yoga
  • trying acupuncture
  • using an abdominal binder for compression

However, some mild-to-moderate CSF symptoms may get better without any treatment.

Medication

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

(Video) Upright Headache - my spinal CSF leak

However, researchers are yet to prove the effectiveness of most of these. In fact, some of these medications may carry serious health risks, including disability.

Some medications for CSF leak symptoms include:

  • theophylline
  • antinausea medications such as ondansetron
  • nonopiate pain medications

Epidural blood patch

People with CSF leaks may also need to undergo an epidural blood patch (EBP). This is a procedure wherein a doctor injects 10–100 milliliters of a person’s own blood into the epidural space in their spinal canal.

This creates a patch on the outer layer of the meninges, which seems to reduce CSF loss.

A doctor will perform an EBP procedure at the location of a leak, or in the middle or lower parts of the spine if they do not know the exact location of the leak.

Health professionals do not know exactly why this procedure seems to help manage CSF leaks. However, at the very least, it 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 an EBP procedure.

Blood patching usually brings instant relief of symptoms, but its effect can wear off, causing the need for multiple procedures.

Surgery

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

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

Managing symptoms

There is no cure for POTS. However, increasing blood volume and helping regulate circulatory conditions can help.

Some medications and lifestyle changes that may assist in this include:

  • increasing fluid intake
  • exercising regularly at a gradual pace
  • increasing salt intake
  • taking fludrocortisone, if on a high salt diet
  • taking low dose midodrine
  • taking beta-blockers

Risk factors

(Video) What Causes Headaches? Intro to Postural Headaches

It is difficult to reduce the risk of positional headaches, apart from by practicing good safety, sticking to healthful habits, and addressing any underlying health conditions.

There are several different factors that can increase the risk of developing a CSF leak, which is a common cause of positional headaches. These include:

  • sneezing or coughing too hard or frequently
  • straining too hard during exercise or activities
  • roller-coaster rides and other jerky, position-changing activities
  • medical procedures, such as lumbar punctures
  • fistulas, or abnormal pockets of tissue
  • certain genetic or hereditary conditions, such as Chiari malformations and polycystic kidney disease
  • tumors or cysts in the head, neck, or spine

For the conditions that cause positional headaches, receiving an early diagnosis and prompt treatment usually reduces the risk of serious complications.

See a doctor as soon as possible or seek emergency care if any warning signs of CSF leaks or POTS accompany positional headaches.

Some warning signs of a CSF leak include:

  • nausea and vomiting
  • neck pain or stiffness
  • sensitivity to light and sound
  • balance problems
  • ringing in the ears, muffled hearing, or hearing loss
  • pain between the shoulder blades
  • brain fog
  • dizziness or vertigo
  • facial pain or numbness
  • pain or numbness in the arms or below them
  • double vision or blurred vision
  • chest or back pain
  • fatigue
  • changes to how things taste
  • nipple discharge
  • racing heartbeat or rapid changes in blood pressure when changing position
  • fainting when standing up

Positional headaches usually occur while a person is standing or sitting upright and improve when they lie down. Only a few conditions can cause them, most notably CSF leaks and POTS.

Some CSF leaks resolve without treatment, whereas others require lifestyle changes, medications, EBP procedures, or surgical repairs.

(Video) Spontaneous Low CSF Pressure Headache

Treatments for most CSF leaks tend to be successful, but some people may continue to have symptoms and disability after several treatments.

There is no cure for POTS, but people can manage it by making lifestyle changes and taking medication to control blood pressure and volume.

To reduce the risk of complications, speak to a doctor about any unexplained, chronic, or severe headaches, especially those that change with position.

FAQs

What causes a positional headache? ›

The cause of a positional headache is often low spinal fluid pressure inside the head, which occurs in a condition called intracranial hypotension. Intracranial hypotension generally relates to a loss or imbalance of CSF. CSF cushions the brain and spinal cord within special membranes called meninges.

How long does it take for a positional headache to go away? ›

The most common symptom of SIH is a “typical” headache, located in the back of the head, often with neck pain. It is worse when standing or sitting and improves or goes away within 20-30 minutes of lying down, called “orthostatic” or “postural” headache. The pain is often very severe.

Is a positional headache serious? ›

We call that a "postural" headache, and it can be a sign of masses putting pressure on the brain or spinal cord, and has been known to happen with blood-clotting events in the brain. This type can also present as a new morning headache that's severe and might come with vomiting.

Can sinus cause positional headache? ›

Examples of bacterial and viral infections that can cause a headache and dizziness include: the flu. a common cold. sinus infections.

Can dehydration cause positional headache? ›

Insider's takeaway. Headaches are a common symptom of being dehydrated. Normally, a dehydration headache is a bilateral throbbing sensation and may feel worse during activity or in certain positions. You may also feel fatigue, dry mouth, and confusion.

What kind of headache gets worse when you lay down? ›

Idiopathic intracranial hypotension (pseudotumor cerebri) headache may be worse when lying down and can disrupt sleep.

What kind of headache causes pain when you bend over? ›

Sinus headache causes pain in the front of the head and face. It is due to swelling in the sinus passages behind the cheeks, nose, and eyes. The pain is worse when you bend forward and when you first wake up in the morning.

Why do I have pressure in my head everyday? ›

Conditions that might cause nonprimary chronic daily headaches include: Inflammation or other problems with the blood vessels in and around the brain, including stroke. Infections, such as meningitis. Intracranial pressure that's either too high or too low.

What are the red flags for headaches? ›

“Red flags” for secondary disorders include sudden onset of headache, onset of headache after 50 years of age, increased frequency or severity of headache, new onset of headache with an underlying medical condition, headache with concomitant systemic illness, focal neurologic signs or symptoms, papilledema and headache ...

How do you check for CSF leak? ›

CT myelography.

This test is considered the gold standard for diagnosing and locating CSF leaks. It uses a CT scan and a contrast dye to locate CSF leaks anywhere in the skull base. It provides the most precise location of a CSF leak and helps to determine the most appropriate treatment plan.

How do I know if I have a Cervicogenic headache? ›

Cervicogenic headache usually begins as a dull ache in the neck and radiates upward along the back of the head, almost always one-sided. Pain may also spread to the forehead, temple, and area around the eyes and/or ears. CGH is caused due to an underlying disc, joint, muscle, or nerve disorder in the neck.

Why does my head feel heavy and pressure? ›

Anxiety can cause a heavy head feeling because of a type headache known as a tension headache that is common in people with anxiety disorders. These headaches are often described as feeling like there's a tight band wrapped around your head. They're caused by a tightening of the neck and scalp muscles.

What does a spinal headache feel like? ›

Spinal headache symptoms include: Dull, throbbing pain that varies in intensity from mild to very severe. Pain that typically gets worse when you sit up or stand and decreases or goes away when you lie down.

What does an anxiety headache feel like? ›

These are more severe headaches that can cause painful pounding or throbbing. They can last for hours or even days. Besides pain, migraines can also make you vomit and feel sensitive to light and noise. They're very common in people who have anxiety disorders.

What is a good sinus headache medicine? ›

Medications include sumatriptan (Imitrex, Tosymra, others), rizatriptan (Maxalt), almotriptan, naratriptan (Amerge), zolmitriptan (Zomig), frovatriptan (Frova) and eletriptan (Relpax). Triptans are available as tablets, nasal sprays and injections.

How do you relieve sinus pressure in the back of your head and neck? ›

How do I get rid of a sinus headache?
  1. Apply a warm compress to painful areas of the face.
  2. Use a decongestant to reduce sinus swelling and allow mucus to drain.
  3. Try a saline nasal spray or drops to thin mucus.
  4. Use a vaporizer or inhale steam from a pan of boiled water. Warm, moist air may help relieve sinus congestion.
18 Aug 2020

How do you stop sinus headaches? ›

How to Prevent Sinus Headaches
  1. Take Care of Your Sinuses. Sinus headaches are often the result of sinusitis, which is inflammation of the sinuses. ...
  2. Avoid the Triggers. A sinus headache can be triggered by certain odors and foods. ...
  3. Improve Indoor Air Quality. ...
  4. Massage the Area. ...
  5. Drink Plenty of Water. ...
  6. When to See a Doctor.
5 Sept 2016

Does drinking water help headaches? ›

Clinical bottom line: Water intake is a cost effective, non-invasive and low-risk intervention to reduce or prevent headache pain. Rationale: Chronic mild dehydration may trigger headache. Increased water intake could help.

How much water should I drink to get rid of a headache? ›

Most dehydration headaches resolve within three hours of drinking. You don't need to overhydrate: A simple glass or two of water should help in most cases. Drinking too quickly sometimes makes dehydrated people vomit, so it's best to take slow, steady sips. You could even suck on a few ice cubes.

What are the signs of drinking too much water? ›

Thirst is the body's response to dehydration and should be your guiding cue.
  • Nausea or vomiting. The symptoms of overhydration can look like those of dehydration. ...
  • Throbbing headaches all through the day. ...
  • Discoloration of the hands, feet, and lips. ...
  • Weak muscles that cramp easily. ...
  • Tiredness or fatigue.
8 Apr 2021

Why does my headache won't go away? ›

Anxiety, stress, and mood disorders can trigger headaches that linger for more than a day. Specifically, those with panic disorder or generalized anxiety disorder tend to experience prolonged headaches more often than those without.

Why does my pillow give me a headache? ›

Pillows that are too high can cause the head and neck to round forward adding tension to the suboccipital neck muscles. Too much tension in these muscles may result in you waking up with a headache or developing a headache in the morning once you've gotten out of bed.

Why does my head hurt when I lay on my pillow? ›

The primary cause of waking up from headaches is the misalignment of the neck and spine. Lying on pillows that are too thin or too thick tilts the head in an awkward position, affecting alignment and often leading to headaches or neck pain.

What causes pain behind the ear down the neck? ›

Occipital Neuralgia is a condition in which the occipital nerves, the nerves that run through the scalp, are injured or inflamed. This causes headaches that feel like severe piercing, throbbing or shock-like pain in the upper neck, back of the head or behind the ears.

What are symptoms of a sinus headache? ›

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  • Pain, pressure and fullness in the cheeks, brow or forehead.
  • Worsening pain if you bend forward or lie down.
  • Stuffy nose.
  • Fatigue.
  • Achy feeling in the upper teeth.
17 May 2022

What does a dehydration headache feel like? ›

Pain from a dehydration headache can range from mild to severe. You may feel pain all over your head or in just one spot, such as the back, front or side. The pain is usually like a dull ache, but it can also be sharp. You may have a throbbing (pounding) headache, or the pain might be constant.

When should I see a neurologist for headaches? ›

Consider making an appointment with a neurologist if: Your headache is continuous for more than a day or two. Your headaches tend to come on suddenly. Your head pain is worsened by straining.

Why do I wake up with a headache every day? ›

A number of sleep or health disorders, as well as personal habits, can trigger a headache when you wake up. Sleep apnea, migraine, and lack of sleep are common culprits. However, teeth grinding, alcohol use, and certain medications can also cause you to wake up with a headache.

What causes headaches everyday in females? ›

In women, fluctuating hormone levels are a major contributing factor in chronic headaches and menstrual migraines. Hormone levels change during the menstrual cycle, pregnancy, and menopause, and are also affected by oral contraceptives and hormone replacement therapies.

What can an MRI show for headaches? ›

In some migraine patients, an MRI may show white spots on the brain. These spots are called white matter hyperintensities (WMHs), which are lesions in the brain visualized by areas of increased brightness. They can vary in size and location in areas of the brain.

What can a CT scan show about headaches? ›

Imaging tests rarely help.

Health care providers see many patients for headaches and most of them have migraines or headaches caused by tension. Both kinds of headaches can be very painful, but a CT scan or an MRI rarely shows why the headache occurs. Having a CT scan or MRI also does not help ease the pain.

How can a neurologist help with headaches? ›

Neurologists are knowledgeable about the latest treatments for migraine attacks and can help develop an appropriate treatment plan and fine-tune any medications that may be helpful for you.

What does a CSF leak headache feel like? ›

The headache is generally worse shortly after sitting up or standing and improves relatively quickly when laying down, hence it is often referred to as an “orthostatic” or “postural” headache. The pain can range from mild to severe and can feel more like pressure than pain and be accompanied by a heaviness.

What color is CSF fluid? ›

Cerebrospinal fluid (CSF) is a clear liquid that surrounds the brain and spinal cord. It provides a cushion for delicate brain and spinal tissue. Reduced cerebrospinal fluid, as in the case of a leak, requires immediate care by a trained expert.

Will an MRI show a CSF leak? ›

Magnetic resonance imaging (MRI) accurately detects CSF leaks and associated complications such as the encephaloceles and meningoceles.

What is the best treatment for cervicogenic headache? ›

Most cervicogenic headaches get better with physical therapy and pain relievers. In some cases, a minimally invasive pain relief procedure such as a nerve block can be helpful.

What type of doctor treats cervicogenic headaches? ›

Other providers that may need to be involved in management of cervicogenic headache include physical therapists, pain specialists (who can do the injections/blocks), and sometimes neurosurgeons or orthopedic surgeons.

What kind of tumor causes cervicogenic headache? ›

Nasopharyngeal cancer can occur in any age group and is often misdiagnosed. Cervicogenic headache (CEH) is a clinical condition, putatively originating from nociceptive structures in the neck. A patient with CEH-like symptoms occurring as a result of nasopharyngeal cancer invasion is reported.

What kind of headache gets worse when you lay down? ›

Idiopathic intracranial hypotension (pseudotumor cerebri) headache may be worse when lying down and can disrupt sleep.

What position should I sleep in with a headache? ›

If you struggle from migraines, as above, make sure you're sleeping on your back or on your side. They're the best positions, generally speaking, to support your body through sleep sans pain.

How do I know if I have a Cervicogenic headache? ›

Cervicogenic headache usually begins as a dull ache in the neck and radiates upward along the back of the head, almost always one-sided. Pain may also spread to the forehead, temple, and area around the eyes and/or ears. CGH is caused due to an underlying disc, joint, muscle, or nerve disorder in the neck.

What does a dehydration headache feel like? ›

Pain from a dehydration headache can range from mild to severe. You may feel pain all over your head or in just one spot, such as the back, front or side. The pain is usually like a dull ache, but it can also be sharp. You may have a throbbing (pounding) headache, or the pain might be constant.

What are the red flags for headaches? ›

“Red flags” for secondary disorders include sudden onset of headache, onset of headache after 50 years of age, increased frequency or severity of headache, new onset of headache with an underlying medical condition, headache with concomitant systemic illness, focal neurologic signs or symptoms, papilledema and headache ...

Why does my headache won't go away? ›

Anxiety, stress, and mood disorders can trigger headaches that linger for more than a day. Specifically, those with panic disorder or generalized anxiety disorder tend to experience prolonged headaches more often than those without.

Why does my pillow give me a headache? ›

Pillows that are too high can cause the head and neck to round forward adding tension to the suboccipital neck muscles. Too much tension in these muscles may result in you waking up with a headache or developing a headache in the morning once you've gotten out of bed.

What vitamins help with headaches? ›

Vitamins and Supplements for Headache Treatment
  • Magnesium.
  • Riboflavin.
  • Feverfew.
  • Coenzyme Q10.
  • Melatonin.

Can a low pillow cause headaches? ›

If your pillow offers improper support you might wake up with a tension headache. A pillow that does not hold your head and neck in a neutral alignment with your spine can lead to neck pain and headaches.

What kind of tumor causes Cervicogenic headache? ›

Nasopharyngeal cancer can occur in any age group and is often misdiagnosed. Cervicogenic headache (CEH) is a clinical condition, putatively originating from nociceptive structures in the neck. A patient with CEH-like symptoms occurring as a result of nasopharyngeal cancer invasion is reported.

What is the best treatment for cervicogenic headache? ›

Most cervicogenic headaches get better with physical therapy and pain relievers. In some cases, a minimally invasive pain relief procedure such as a nerve block can be helpful.

What type of doctor treats cervicogenic headaches? ›

Other providers that may need to be involved in management of cervicogenic headache include physical therapists, pain specialists (who can do the injections/blocks), and sometimes neurosurgeons or orthopedic surgeons.

Do neurologists treat cervicogenic headaches? ›

Migraine, sinus headaches, tension type headaches, rebound, cervicogenic, cluster, and autonomic cephalalgias require a headache neurologist.

What is a hypertension headache? ›

What can a hypertension headache feel like? Headaches triggered by high blood pressure typically cause a pulsing sensation that's felt all over the head rather than on just one side. If your headache is severe, happens suddenly, or is accompanied by chest pain or shortness of breath, get immediate medical attention.

Can drinking water cure a headache? ›

Clinical bottom line: Water intake is a cost effective, non-invasive and low-risk intervention to reduce or prevent headache pain. Rationale: Chronic mild dehydration may trigger headache. Increased water intake could help.

What are the signs of drinking too much water? ›

Thirst is the body's response to dehydration and should be your guiding cue.
  • Nausea or vomiting. The symptoms of overhydration can look like those of dehydration. ...
  • Throbbing headaches all through the day. ...
  • Discoloration of the hands, feet, and lips. ...
  • Weak muscles that cramp easily. ...
  • Tiredness or fatigue.
8 Apr 2021

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