Why Do I Get a Headache When Standing Up?

If you experience a headache when standing, it may be due to low cerebrospinal fluid (CSF). A CSF headache is one type of positional headache that arises due to insufficient spinal fluid pressure on the brain. Other causes of positional headaches could relate to the neck or the autonomic nervous system, among other conditions.

The primary characteristic of a low CSF pressure headache is pain that starts or worsens when you sit up or stand and goes away when you lie down. Low spinal fluid is not always dangerous, and a mild to moderate case of low CSF can resolve on its own or with at-home treatment.

This article provides a brief overview of low CSF pressure headaches, including causes and symptoms. It also discusses diagnosis and treatment.

What Is a Low CSF Pressure Headache?

Low CSF pressure headache is a secondary headache disorder, meaning it’s caused by another condition, rather than arising independently. The symptoms come on due to insufficient amounts of cerebrospinal fluid, which protects the brain and spinal cord when you move.

The pain and other symptoms arise as the brain moves excessively and distresses surrounding nerves. This condition is sometimes also called a "positional headache" because it arises—and goes away—due to changes in the position of your head. With this type, the pain and other symptoms begin when you are upright and go away when you lie down.

Symptoms of a Low CSF Pressure Headache

The primary symptom of positional headache due to low CSF pressure is head pain that gets worse when you stand up or move and eases off when you lie down. For some, it comes on quickly. For others, it has a more gradual onset.

Typically, the symptoms start within 15 minutes of being upright and go away 15–30 minutes after lying down. In some cases, however, the time between onset and improvement can take one or more hours.

Pain with positional headache due to low CSF pressure ranges from dull and manageable to severe and debilitating. These headaches are typically:

• Localized to the back of the head or base of the skull
• Less often felt in the front, sides, or all over the head
• Felt on both sides of the head, as opposed to just one side
• Described as a “pulling back" from the back of the head to the neck

In addition, these headaches may cause:

• Neck pain and stiffness
• Nausea and vomiting
• Light and sound sensitivity
• Ringing in the ears (tinnitus) or hearing loss
• Loss of balance
• Fatigue
• Pain between the shoulders or in the upper arms
• Changes in vision
• Dizziness and vertigo
• Facial numbness
• Changes in the sense of taste

Causes of a Low CSF Pressure Headache

Low CSF pressure headaches primarily occur due to insufficient levels of cerebrospinal fluid, the fluid that surrounds the brain and spinal cord (which make up the central nervous system). This is caused by a deformity or tear in the dura mater, the tough outermost layer of the tissues (meninges) that surround the central nervous system.

The CSF loss lowers the pressure it places on the brain, called intracranial hypotension, leaving this vital organ with less support. When standing or when upright, it sinks to a lower-than-natural position, which stretches the surrounding meninges and nerves, causing pain.

CSF leaks can be brought on by:

• Dural sac tear, a complication of spinal surgery or epidural anesthesia (medicines to numb pain that are given in the epidural space around the spinal cord)
• Spinal tap (lumbar puncture), removing CSF with a needle inserted between two vertebrae
• Head or neck trauma due to a fall or impact
• Heavy sneezes or coughing

CSF leaks can also occur without any identifiable cause.

Risk Factors

CSF leaks are more common in people who are:

• Female
• Diagnosed with connective tissue disorders/thin dura mater
• Double-jointed or unusually flexible
• Tall and thin

Diagnosing Low CSF Pressure Headaches

Low CSF pressure headaches are typically treated by a team of healthcare providers that may include emergency medicine physicians, neurologists, neurosurgeons, anesthesiologists, pain specialists, and geneticists, along with your primary care provider.

Diagnosis of this condition can be difficult, especially when the symptoms are mild to moderate. Several procedures and tests may be involved, including:

• A physical evaluation and medical history
• Imaging (e.g., magnetic resonance imaging (MRI), Computerized tomography (CT) with IV contrast agent, or cisternogram)
• A spinal tap

Other Causes of Headaches When Standing Up

In addition to CSF leaks, positional headaches may be caused by:

• Structural neck problems: Cervicogenic headaches are associated with problems in the neck, including deformity in the structure of the vertebrae, compaction of disks between them, and problems with nerves and blood flow.
• Postural orthostatic tachycardia syndrome (POTS): This condition is caused by changes or abnormalities in the autonomic nervous system (dysautonomia) that result in unpleasant symptoms when standing up. POTS headaches may be mistaken for low CSF pressure headaches, but the two conditions can also coincide.
• Dehydration: Severe dehydration can cause a sharp drop in blood pressure when standing up, which can trigger a headache.
• Orthostatic hypotension: In those with low blood pressure (below 90/60 mmHg), blood pressure can dip further with postural changes, like sitting up or standing, resulting in headaches.
• Anemia or blood loss: Significant blood loss decreases blood flow to the brain, causing headaches that worsen when standing up.
• Brain tumors: Tumors can block the flow of CSF to the brain. This is a relatively rare cause.
  

Treatment

Treatment for positional headaches due to low CSF pressure can be challenging since most standard headache therapies don’t work. Therapy is successful when the tear or malformation in the spinal meninges is closed, stopping the CSF leak. There are several interventions that healthcare providers try.

Rest and Recovery

As noted, lying down for some time should relieve the headache. The first line of treatment for milder cases involves bed rest, increasing fluids to stay hydrated, and taking caffeine (either as coffee or tea or in pill form). Given time, many cases resolve without additional treatment.

Epidural Blood Patch

If the headache doesn’t resolve on its own, an epidural blood patch procedure is the standard treatment. The specialist, usually an anesthesiologist, takes blood from a vein and injects it near the hole in the meninges or at a safe distance if the exact location is unknown.

This blood forms a clot at the rupture, providing nearly instantaneous relief of symptoms. This therapy may need to be repeated.

Surgical Repair

If the exact location of the tear in the meninges is known, repair of the site can be considered. Using X-ray imaging as a guide, an interventional radiologist can use a specialized needle to deliver adhesive to the tear. If there’s a larger tear in the spine, a neurosurgeon may attempt surgery to repair it.

Complications

Positional headaches due to low CSF pressure can occasionally lead to serious complications. This can cause symptoms that resemble other conditions, including:

• Frontotemporal dementia, which affects the frontal and temporal lobes of the brain and causes personality, memory, and behavioral changes
• Parkinson’s disease, a progressive neurological disease leading to tremors, slowed movements, rigidity, and loss of balance
• Superficial siderosis, a chronic condition of the central nervous system (CNS) characterized by hearing loss, difficulty moving, and jerky movements    
• Ataxia, a loss of muscle control causing interrupted or affected walking or movement
• Quadriplegia, the paralysis of all four limbs
• New daily persistent headache, a rare primary headache disorder that does not stop

Complicated cases can lead to loss of consciousness, coma (a state of prolonged unconsciousness), strokes (blood supply to the brain is interrupted or reduced), and even death.

When to Seek Medical Care

Medical care is called for if you experience low CSF pressure headache symptoms, and certainly if you experience the other symptoms of a CSF leak. Get help if you experience:

• Worsening headache
• Very rapid onset of severe headache
• Neck pain and stiffness
• Balance problems, dizziness, or vertigo
• Ringing in the ears
• Facial pain
• Visual disturbances, double vision
• Pain between the shoulder blades and/or in the arms
• Racing heartbeat when changing position
• Memory and speech problems

Summary

Low CSF pressure headaches may arise due to insufficient cerebrospinal fluid pressure on the brain, which can occur due to a dural sac tear, spinal tap, trauma of the head or neck, or heavy sneezes or coughing. This type of headache is characterized by pain and other symptoms when sitting up or standing, which go away when lying down.

Low CSF pressure headaches are usually treated by a team of neurological experts using a variety of diagnostic imaging techniques. Treatment depends on the severity of the condition but includes rest and hydration. An epidural blood patch and surgical repair may also be necessary. Complications are rare but can be serious.