Positional Headache

What is a positional headache?

A positional headache is head pain that gets worse when you sit or stand and gets better when you lie down. Another name for a positional headache is an orthostatic headache. Orthostatic means “in an upright position.” You might also feel this headache if you bend over, sneeze, strain or lift heavy objects.

You might feel pain in the back of your head when you stand up, but it can affect any part of your head. This pain can get worse throughout the day. Sometimes, other symptoms happen alongside a positional headache like nausea and neck stiffness.

How common is a positional headache?

Positional headaches are a common side effect after a lumbar puncture (spinal tap) diagnostic test. Many people feel this headache 24 to 48 hours after the test.

Are positional headaches dangerous?

A positional headache can be a sign that something’s wrong. Sometimes, these headaches are temporary and resolve on their own. But it’s best to talk to a healthcare provider if you experience sudden headaches when you change position instead of leaving it up to chance. A positional headache can indicate a more serious condition like fluid loss, a brain tumor or a change in pressure within your skull.

What are the symptoms of a positional headache?

The main symptom of a positional headache is a headache or head pain. Features of this symptom include:

• Headache gets worse when standing or sitting upright.
• Pain is usually in the back of your head.
• Head pain is throbbing or aching.
• Pain increases in severity throughout the day.
• Pain gets better when you lie down.

Other symptoms that can happen with a positional headache include:

• Nausea and vomiting.
• Dizziness.
• Stiff neck.
• Pain between your shoulder blades.
• Ringing in your ears (tinnitus).
• Difficulty with balance.
• Sensitivity to light and sound.
• Numbness or tingling in your arms.
• Difficulty with focus and concentration (brain fog).

What causes a positional headache?

There could be many possible causes of a positional headache, but the most common is a change to cerebrospinal fluid (CSF) volume like a CSF leak. CSF is the fluid that surrounds your brain and spinal cord. It acts as a cushion to protect your central nervous system.

If you undergo a lumbar puncture where a healthcare provider removes a small amount of CSF from your spinal canal to examine it, the amount of CSF in your body changes. The volume can also change if you experience a traumatic injury, ruptured cyst or have a tear in connective tissue that holds this fluid in place (dura mater).

When you lose CSF volume, your brain changes position to make up for the loss. Your brain, like a buoy in water, moves when you lie down or stand up. As a result, your brain makes contact with sensitive membranes in your skull that cause head pain.

Other possible causes of a positional headache include:

• Postural orthostatic tachycardia syndrome (POTS).
• Spontaneous intracranial hypotension (SIH).
• Cervical spine (neck) conditions that affect your disks, joints, muscles and connective tissues.
• Chiari malformation.
• Ehlers-Danlos syndrome.
• Tumor or cyst on your spine.

What are the risk factors for a positional headache?

You’re more at risk of developing a positional headache if you:

• Underwent a lumbar puncture procedure recently.
• Experienced a traumatic injury.
• Have a condition that affects your spine.

What are the complications of a positional headache?

If a cerebrospinal fluid leak causes a positional headache, fluid loss around your brain and spinal cord could be dangerous. Without CSF protection, your brain is vulnerable to damage. Complications of untreated CSF leaks include:

• Frequent headaches.
• Neck pain.
• Hearing problems.
• Loss of smell and taste.
• Infection (meningitis).
• Bleeding in the brain.

How is a positional headache diagnosed?

A healthcare provider will diagnose a positional headache after a physical exam, neurological exam and testing. An imaging test, like an MRI or CT scan, helps detect the cause of your symptoms.

Your provider will also gather more information about you, like your health history. If you experienced an injury, let your healthcare provider know.

If you recently underwent a lumbar puncture, your provider will expect positional headaches as a side effect and no further exam or testing is necessary unless your symptoms persist.

How do I get rid of a positional headache?

A positional headache will go away if you lie down. While this is a temporary solution, it can relieve immediate head pain. But it doesn't cure positional headaches.

A healthcare provider can help you find a treatment option to address the cause of your headache. This could include treating any underlying health conditions in addition to non-medication treatment options for the headache itself, like:

• Getting plenty of bed rest.
• Staying hydrated.
• Taking a caffeine supplement or drinking a caffeinated beverage.

If a positional headache is a side effect of a lumbar puncture, your provider may give you instructions to rest for a couple of days after the procedure. This could include:

• Lying down.
• Staying hydrated.
• Wearing a compression garment around your abdomen.
• Taking pain reliever (analgesics) medications as directed.

Let your provider know if a positional headache lasts longer than 48 hours after a lumbar puncture.

For positional headaches caused by a CSF leak that doesn’t resolve with noninvasive options, your provider might use an epidural blood patch. To do this, a healthcare provider will remove a small amount of blood from your body. Then, they’ll inject your blood back into the epidural space. This is the fluid-filled area between the dura mater (membrane) and your vertebrae (spine). An epidural blood patch can stop a CSF leak.

Surgery is an option to treat conditions that affect your spine or CSF leaks that don’t resolve with nonsurgical treatments.

Can a positional headache be prevented?

You can’t prevent all causes of a positional headache. Your best option to prevent head pain if you have a positional headache is to rest and follow the treatment instructions that your provider gives you.

What’s the outlook for a positional headache?

A positional headache is usually temporary. If you have a positional headache when you stand up, it can go away when you lie down and rest for about 30 minutes. This headache can get worse if you’re active and in an upright position for most of the day.

Some positional headaches resolve on their own, but you should always see a healthcare provider if you have unusual headaches. Sometimes, the underlying cause needs attention. An early diagnosis and treatment can lead to the best outcome.

When should I see a healthcare provider?

Visit a healthcare provider if you get headaches when you change position, like standing up. Your provider can help you manage these and their underlying cause. If you experience a headache that gets worse when you lie down, this would also be a reason to visit a healthcare provider.

If you experience any other symptoms along with positional headaches, contact a healthcare provider.

What questions should I ask my healthcare provider?

• What’s causing positional headaches?
• How long do I need to rest?
• What activities are safe to do after a lumbar puncture?
• What type of treatment option do you recommend?
• Are there side effects of treatment?
• How long can I expect to have a positional headache?