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What To Know About Positional Headaches

A positional headache is one that occurs when sitting or standing and improves when lying down. Bending, sneezing, lifting, and straining may also cause it. It often results from a leak of cerebrospinal fluid (CSF) and symptoms usually localize to the back of the head.

Positional headaches are also known as orthostatic, postural, and low pressure headaches.

As well as leaks of CSF, other conditions can cause positional headaches. 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.

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
  • 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 bedridden for a long period of time, such as during a prolonged hospitalization.

    Anyone at any age can develop POTS, but it mainly affects women between the ages of 15 to 50 years of age. Some women report an increase in episodes of POTS right before their menstrual periods. POTS often begins after a pregnancy, major surgery, trauma, or a viral illness.

    In fact, it has been diagnosed in individuals following infection with COVID-19. People who have long COVID (sometimes called long haulers) may develop POTS. It may make individuals unable to exercise because the activity brings on fainting spells or dizziness.

    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.

    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.

    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.

    The blood will form a clot which creates a patch on the outer layer of the meninges, which can effectively stop 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
  • 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.

    Treatments for most CSF leaks tend to be successful, but some people may continue to have symptoms and persistent 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.


    What Are Cluster Headaches?

    Cluster headaches cause severe pain around the eye, usually on one side of the head. The pain is stabbing, sharp, or burning rather than throbbing. They start suddenly, occur in groups or clusters, and can last from 15 minutes to several hours.

    Cluster headaches occur cyclically. A bout of regular attacks, known as a cluster period, can last a few days, weeks, or months. During remission periods, a person has no headaches.

    Cluster headaches are not common, affecting about 1 in 1,000 people. Six out of 10 cases involve men, and most of these are people who smoke. The headaches usually start after the age of 20.

    Keep reading to learn more about cluster headaches, including the symptoms, causes, and treatment methods.

    Here are some key points about cluster headaches.

  • Cluster headaches typically affect one side of the head and the area around the eyes. Symptoms may include a reddened eye on the affected side of the head and a stuffy nose.
  • In northern countries, they are more common during the fall.
  • They affect around 1 in 1,000 people and are more common in men than women.
  • A cluster headache often appears suddenly, lasts around 1 hour, then disappears.
  • During a cluster period, headaches happen frequently. During remission, there is no pain.
  • Symptoms of cluster headaches include intense pain that starts rapidly and usually without warning. The pain is continuous rather than throbbing. It may cause a stabbing, sharp, or burning sensation.

    The pain typically starts around the eye and may radiate to other parts of the head, including the face, neck, and shoulders. Pain may be present in a temple or a cheek. It remains on one side of the head.

    There may also be:

  • restlessness
  • redness, swelling, or watering in the eye on the side of the pain
  • stuffy, blocked, or runny nose on the same side as the pain
  • pale skin
  • facial sweating
  • small pupil size
  • drooping of the eyelid on the same side as the pain
  • The pain can wake a person up during the night, and it may occur at the same time each night.

    Each cluster can last from 15 minutes to several hours, but not usually more than 1 hour. After an attack, the pain will be gone, but the person may feel very tired.

    Timing

    A cluster period usually lasts from 6–12 weeks. It often starts at the same time each month, especially during springtime or fall.

    Cluster headaches are either:

  • Episodic cluster headaches: A series of searing headaches typically lasting from 1 week to 3 months. There is usually a 6–12-month period of remission with no pain after an episode. Then the cycle repeats itself.
  • Chronic cluster headaches: The cluster period can persist for several months, 1 year, or longer. Periods of remission are short, lasting around a month.
  • A cluster period may consist of:

  • daily occurrences, with symptoms appearing several times each day
  • one attack, lasting from 15 minutes to 3 hours
  • attacks that occur around the same time each day
  • attacks that are more likely at night
  • It is not clear exactly why cluster headaches occur.

    Research shows that during an attack there is more activity in the hypothalamus, an area of the brain that controls body temperature, hunger, and thirst.

    This area of the brain releases chemicals that cause blood vessels to widen, resulting in a greater blood flow to the brain. One theory was that this may cause the headaches. However, this theory has since been rejected.

    Other theories relate to inflammatory factors and neurotransmitters. Unfortunately, as this condition is so rare, it is difficult to find larger sample sizes for studies. However, researchers also think there could be a genetic link relating to the cause of the condition.

    Some triggers can cause episodes of cluster headaches, such as alcohol, a sudden rise in temperature, or exercising in hot weather. There are also links between cluster headaches and smoking, irregular sleep-wake cycles, and allergies.

    There is currently no cure for cluster headaches, but drugs and therapies can reduce the incidence and severity of attacks, such as sumatriptan.

    Treatment aims to relieve some of the symptoms, shorten the periods of headaches, and reduce their frequency.

    Over-the-counter (OTC) pain medication such as aspirin or ibuprofen can be too slow to effectively reduce pain before the headache is over.

    Medications and treatments for cluster headaches aim either to prevent them or to act quickly.

    Fast-acting treatments

    A study in 2015 provided clinical guidance on treating cluster headaches, including:

  • Inhaling 100% oxygen: Breathing in oxygen through a mask at 7–10 liters per minute could reduce symptoms within 15 minutes. It is not always practical to have an oxygen cylinder and regulator close at hand, but some small units are available. Oxygen therapy may only postpone symptoms, rather than alleviating them.
  • Injectable sumatriptan (Imitrex): Triptans are a class of drug that can treat migraine. Sumatriptan can treat migraine and cluster headaches. The adult dose is a 6-milligram (mg) injection. People with high blood pressure or heart disease should avoid this drug.
  • Dihydroergotamine: This is an effective pain reliever for some people. A medical professional will need to give an intravenous dose, but people can also inhale the medication. The inhaler form is effective but slower-acting.
  • Octreotide (Sandostatin): These are synthetic versions of somatostatin, a brain hormone. It is an effective treatment for cluster headaches that is safe for those with hypertension or heart disease.
  • Local anesthetic nasal drops: Lidocaine (Xylocaine) is an effective treatment for cluster headaches.
  • Surgery: This may be an option if drug treatments do not work, or if the person cannot tolerate the medications. The surgery could involve cutting part of the trigeminal nerve, which serves the area behind and around the eye.
  • Possible future treatments

    Some new treatment options under investigation include:

  • Occipital nerve stimulation: This involves implanting a small device over the occipital nerve. It sends impulses via electrodes.
  • Deep brain stimulation: This involves implanting a stimulator in the hypothalamus to change the electrical impulses in the brain.
  • Preventive treatment

    People with cluster headaches take short- and long-term medications. When each period of clusters is over, the short-term treatments stop but the long-term ones may continue.

    Short-term drugs

    People typically take short-term medications until one of the long-term medications start working.

    Examples include:

  • Corticosteroids: These steroids suppress inflammation. They are a fast-acting, preventive drug that can help those with new symptoms or those who have long periods of remission and short cluster periods.
  • Ergotamine (Ergomar): This temporarily narrows blood vessels throughout the body. People can take the medication at night before going to bed, but should not mix with triptans. People should avoid using the drug over long periods or if they have poor circulation.
  • Anesthetic on the occipital nerve: Injecting anesthetic can numb this nerve, which is at the back of the head. As a result, pain messages that travel along the nerve pathway are blocked.
  • Long-term drugs

    People may take long-term drugs throughout the cluster period, such as:

  • Calcium channel blockers: People take these during the cluster period and then gradually reduce the dose, although some people may need to use them long term. Side effects include constipation, tiredness, and swollen ankles. Regular heart monitoring is necessary for people taking high doses.
  • Lithium carbonate: This is a treatment for bipolar disorder that is also effective in preventing chronic cluster headaches. Side effects include increased urination, diarrhea, and tremor. Regular blood tests will check for possible kidney damage.
  • Anti-seizure medications: These drugs also offer effective long-term treatments for cluster headaches.
  • Since the causes of cluster headaches remain unclear, there are no proven lifestyle measures for preventing them.

    Identifying and avoiding triggers for cluster headaches could reduce their frequency or severity. Possible triggers include:

  • alcohol
  • some medications, such as inhaled nitroglycerin
  • exercising in hot weather
  • sudden rises in body temperature
  • smoking
  • irregular sleep patterns
  • Cluster headaches and migraine are both severe forms of headache, but they are different and need specific treatments.

    Before a migraine headache, a person will typically experience an "aura," or visual disturbances, including flashing lights or zigzag lines. Migraine can last for up to 72 hours, and commonly involves nausea, vomiting, and sensitivity to light.

    A cluster headache starts and ends suddenly, and it lasts a shorter time. It can feature congestion, watery eyes, and a runny nose. It normally affects only one side of the head, and the eye that is watering is on the same side.

    A person with migraine prefers to lie down during an attack, but people with cluster headaches may find that lying down worsens the pain.

    Risk factors for cluster headaches include:

  • being male
  • being older than 30
  • drinking alcohol
  • prior experience of brain surgery or trauma
  • family history of cluster headaches or migraine headaches
  • Anyone who has regular headaches should see a doctor. Treatment can relieve symptoms, and it may be necessary to rule out any possible underlying causes.

    Vagus nerve stimulation may also be effective.

    Learn more about vagus nerve stimulation here.

    Cluster headaches are painful headaches that can occur several times a day. Episodes typically come in cycles and may occur around the same time each year.

    The symptoms of cluster headaches include sharp, stabbing pain on one side of the head. There can also be restlessness, nasal congestion, and pale skin.

    There is currently no cure for cluster headaches. However, people can take a combination of short- and long-term medications to reduce the frequency and severity of episodes.


    What Is A Sinus Headache?

    A sinus headache is a type of headache that causes pain and pressure in the front of the head and face thanks to inflammation in the sinus passages that are located behind your facial structure.

    Fortunately, there are treatment options available that can help ease your discomfort. There might also be things you can do to prevent future sinus headaches.

    Most noticeably with a sinus headache, you'll feel moderate to severe pain around the sinus area across the front of your face. The sinuses are the hollow spaces behind your forehead, cheekbones, bridge of the nose, and eyes that help produce mucus.

    Sinus headache pain may be constant, throbbing, dull, or gnawing and can become more severe throughout the day. This pain may also get worse when you move your head, bend over, or lie down.

    In addition to the telltale pain that comes along with a sinus headache, many people also report experiencing:

  • Facial pressure
  • Sinus congestion
  • Runny or stuffy nose
  • Watery eyes
  • Eye redness or swelling
  • Nose bleeds
  • Fever
  • These symptoms may be localized to one side or portion of the face, or they may affect both sides of the face equally.

    Editor's Note: What many people assume is a sinus headache is actually likely a migraine headache. Sinus headache symptoms like pain, pressure, and congestion can be pretty similar to some migraine symptoms, but there are a couple key differences. Notably, migraine commonly comes with nausea, vomiting, and discomfort to bright lights or loud sounds. If you're experiencing any of those symptoms, check with a healthcare provider for an accurate diagnosis.

    Design by Health

    A sinus headache develops when the tissue lining the sinus cavities becomes inflamed. This inflammation is known as rhinosinusitis and most commonly happens with a sinus infection. As the tissue inside the sinuses inflame, mucus increases. The trapped air within the sinuses can cause painful pressure, leading to a sinus headache.

    Sinus headaches may also be caused by:

  • Other infections, like the common cold or another respiratory illness
  • Allergies
  • Environmental irritants
  • Nasal polyps
  • Many sinus headaches are actually incorrectly self-diagnosed—meaning that sometimes, what you think may be a sinus headache may actually be another type of headache or condition, such as migraine

    During a medical appointment, the healthcare provider will ask questions about your symptoms and medical history before performing a physical exam. Diagnostic tests can include:

  • Examining your sinuses: They will use a finger to tap on the sinus cavity area for any tenderness or use a small light tool to view the insides of your sinuses through your nose for any swelling.
  • Taking a sample of any mucus: They will test the mucus for bacteria, or sometimes fungi, if a sinus infection is suspected.
  • Ordering imaging: Computed tomography or magnetic resonance imaging can offer a better view inside the sinus cavities to rule out more serious issues such as blockages, tumors, or bleeding around the brain.
  • Referring you for allergy testing: They will want to rule out whether allergies might be the culprit of your sinus headache symptoms like pain and nasal congestion.
  • The International Headache Society offers specific criteria to diagnose a sinus headache. According to those guidelines, to be diagnosed as a sinus headache, the headache must be caused by either acute or chronic/recurring rhinosinusitis. You would also need to meet some other key criteria, such as increased pain when pressure is applied to the sinus area.

    Before starting any at-home treatments, it's important to figure out if what you're experiencing is actually a sinus headache and not another form of headache or illness.

    Treatment options for easing the discomfort of a sinus infection—and in particular, the intense headache that can come along with it—might include:

  • Prescription antibiotics (for a bacterial sinus infection)
  • Decongestants
  • Antihistamines (for an allergy-related sinus headache)
  • Steam for the nasal passages
  • Avoidance of any allergens
  • Surgery to remove polyps or blockages (in severe cases)
  • A sinus headache and its corresponding facial pain or pressure should resolve itself within a week after your sinus infection symptoms have started to dwindle or after you've had a successful course of antibiotics. If you find yourself continuing to experience pain after that period of time, consider checking with a healthcare provider again.

    Because most sinus headaches are the result of rhinosinusitis, prevention tips will focus on keeping your sinuses healthy—both on a regular basis, and during an infection or respiratory illness.

    For example, experts recommend taking steps like:

  • Using a saline nasal spray to clear the nasal passages and reduce swelling
  • Avoiding any allergens or other triggers
  • Trying over-the-counter medications like antihistamines or decongestants, as needed
  • Using a humidifier in your home, particularly in the bedroom
  • Staying hydrated and getting plenty of sleep to help your body fight off infections
  • Applying a warm compress to the sinus area
  • Keeping hands washed to avoid germ transmission, particularly during cold and flu season
  • Sinus headaches happen when the sinuses (empty spaces behind your facial bones) become inflamed or congested. The most noticeable symptoms include head pain and pressure. These headaches usually develop as a result of rhinosinusitis, inflammation of the nasal cavity and sinuses that may come from a sinus infection, allergies, or another respiratory infection. Sinus headache and migraine can be confused for one another, which is why an accurate diagnosis from a healthcare provider is important. From there, treatment options may include prescription or over-the-counter medications.






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