CASE REPORT A case of idiopathic low CSF pressure headache presenting as cough headache Angelo Nuti • Filippo Baldacci • Claudio Lucetti • Cristina Dolciotti • Gabriele Cipriani • Ubaldo Bonuccelli Received: 24 July 2009 / Accepted: 9 February 2010 Ó Springer-Verlag 2010 Abstract Idiopathic low cerebrospinal fluid (CSF) pres- sure headache is considered to be one that worsens within 15 min of sitting-up or standing-up, accompanied by at least one of the following: neck stiffness, tinnitus, hypa- cusia, photophobia and nausea. Several reports suggest that a substantial number of idiopathic low CSF pressure cases do not present typical clinical symptoms and that a con- siderable clinical variability exists. We report the case of an idiopathic low CSF pressure presenting as a cough headache. Keywords Orthostatic headache Á Low cerebrospinal fluid pressure Á Cough headache Introduction Spontaneous low cerebrospinal fluid (CSF) pressure is a diffuse/dull headache that worsens within 15 min of sit- ting-up or standing-up (orthostatic headache); it is accompanied by at least one of the following: neck stiff- ness, tinnitus, hypacusia, photophobia and nausea [1]. Further, neuroradiological investigation can show a diffuse pachymeningeal enhancement on magnetic resonance imaging (MRI) with gadolinium [2, 3], and CSF opening pressure in sitting position is usually low ( \ 60 mmH 2 O) [1]. Several reports suggest that a substantial number of idiopathic low CSF pressure cases do not present typical clinical symptoms and that a considerable clinical vari- ability exists [2, 4–7]. This clinical heterogeneity might be the reason why idiopathic low CSF pressure headache is commonly misdiagnosed. We report a case of idiopathic low CSF pressure head- ache presenting as a cough headache. Case report A 23-year-old woman with an unremarkable medical his- tory was observed for a 2-month history of headache pre- cipitated by cough and sudden Valsalva manoeuvres. The pain was aching, bilateral, centred on the bitemporal region, with an average lasting of 15 min (range of dura- tion 5–30 min) and sometimes of high intensity (8/10 in a verbal numeric scale) that created interference with daily activities. The attacks were 2–3 per day. No history of recent trauma has been reported. She had tried common antiinflammatory drugs such as acetaminophen and ibu- profen which failed to give pain relief. Neurological evaluation as well as routine blood examinations were both negative. A brain MRI with gadolinium demonstrated diffuse, smooth non-nodular pachymeningeal enhancement (Fig. 1). Hence, a CSF examination was performed and low opening pressure (44 mmH 2 O) was observed. The patient received a conservative treatment (bed rest, hydration, dexamethasone 8 mg/day for 5 days and 4 mg/ day for further 5 days) with complete resolution of the clinical picture within 3 weeks (the headache becomes mild in only few days, and epidural blood patch was not performed according to the patient). A. Nuti Á C. Lucetti Á C. Dolciotti Á G. Cipriani Neurology Unit, Hospital of Viareggio, Lido di Camaiore, LU, Italy F. Baldacci Á U. Bonuccelli Neurosciences Department, University of Pisa, Pisa, Italy F. Baldacci (&) Via Aurelia 335, 55043 Lido di Camaiore, LU, Italy e-mail: f.baldacci79@yahoo.it 123 Neurol Sci DOI 10.1007/s10072-010-0240-6