Positional Headache: Causes, Symptoms, & Treatment

By John Bernard, MD
Medically reviewed checkmarkMedically reviewed
May 12, 2020

Headaches can be symptoms of a wide variety of conditions, ranging in severity from a mild inconvenience to a serious health issue. If you wake up one day with a throbbing headache in the morning that worsens as you go about the day, keep a close eye on your symptoms. This may be the first sign of a low pressure headache, also known as a positional headache, which generally requires medical treatment.

To better identify what type of headache you’re experiencing, pay attention to two important clues: which behaviors trigger the pain and which behaviors—if any—alleviate the pain. This can tell you a lot about the nature of your headache and how to treat it.

If you feel a throbbing or pounding headache when standing or sitting up, bending over, or working out and the pain subsides when you are lying down, it is very likely a positional headache.

When you’re suffering from a positional headache, the pain is primarily exacerbated and alleviated by your body position. Standing and sitting upright tend to bring on the aching, while lying down reduces or completely eliminates the pain.

What Is a Positional Headache?

A positional headache is characterized by pain in the back of the head that begins or worsens when standing up or sitting, and is eased or alleviated by lying down (typically within 30 minutes or less).

Other names for a positional headache include:

  • Orthostatic headache
  • Postural headache
  • Low pressure headache

If you are still experiencing a headache when lying down for 30 minutes or longer, you likely are not suffering from a positional headache. You may be suffering from a tension headache, migraine, or other common type of headache.

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What Causes a Positional Headache?

The two most common causes of an orthostatic headache are a cerebrospinal fluid (CSF) leak and a condition called postural orthostatic tachycardia syndrome (POTS). In rarer cases, a positional headache may also be a result of several other conditions that affect the nervous system, connective tissue, and bones.

CSF leak

Cerebrospinal fluid (CSF) surrounds the brain and spinal cord, acting as a buffer and cushion that protects them from touching any of your bones when you move. Membranes called meninges hold CSF in place, and if these membranes are damaged, CSF may leak into the body.

A CSF leak presents two primary problems. First, since CSF normally surrounds the spinal cord in ample amounts, standing or sitting up when you have a leak can cause further loss of volume of CSF, resulting in a headache. Lying in a flat position can help to keep more CSF in place surrounding the spinal cord, which is why it eases the pain.

Additionally, the change in pressure caused by a CSF leak impacts the position of the brain, making the brain more likely to come into contact with sensitive parts of the head and spine.

Depending on the extent of damage to the meninges, a CSF leak can range from a mild leak to a severe case that causes chronic pain.

Postural orthostatic tachycardia syndrome (POTS)

POTS is a condition affecting the autonomic nervous system (ANS), hindering the ANS from doing its normal job which is to properly regulate heart function and balance of bodily fluids.

A person with POTS will generally experience spikes in heart rate when switching from a lying or sitting position to standing up. This causes symptoms of dizziness, sudden fatigue, or headache upon standing.

These symptoms may be accompanied by:

It is unclear exactly what causes POTS, though the majority of cases are seen in women between 15-50 years old.

Other causes of a low pressure headache

While the two conditions above are the most common causes, the following health issues may also cause someone to develop a positional headache.

  • Structural neck issues: Conditions that impact the skeletal muscles, intervertebral discs, joints, nerves, blood vessels, or connective tissue in the neck can result in a specific type of positional headache called a cervicogenic headache.
  • Dehydration: When a person is severely dehydrated, they may experience a steep drop in blood pressure when they stand up (due to a lack of body fluids) causing a headache in an upright position.
  • Anemia: Significant blood loss for any reason, including anemia, means less blood is flowing to the brain, which can cause a headache that may worsen when standing up.
  • Brain tumors: Tumors can block the flow of CSF to the brain, causing significant changes in CSF pressure when a person changes positions from lying down to standing up.
  • Trauma or surgical procedures: CSF leaks can occur after trauma to the head or neck, certain spinal surgical procedures or after a lumbar puncture (spinal tap).

Symptoms of Positional Headaches

The primary symptoms of a low pressure headache include pain in the back of the head which may extend into the neck, and a noticeable relief from this pain within 20-30 minutes of lying down. Typically, a positional headache brings severe pain that may feel like throbbing, pounding, stabbing, or aching.

The pain may be triggered or worsened by the following activities:

  • Standing
  • Sitting up
  • Moving
  • Working out
  • Bending over
  • Reaching and stretching
  • Coughing or sneezing
  • Strenuous sexual activity
  • Straining during a bowel movement

Another common symptom of a CSF leak headache is experiencing a mild headache upon waking up that gradually worsens throughout the day.

While orthostatic headaches commonly cause pain originating in the back of the head, the pain can spread to all areas of the head or even be isolated to just one side.

How Do You Diagnose a Positional Headache?

When diagnosing the causes of an orthostatic headache, your doctor will likely seek to rule out a CSF leak or POTS before looking into other sources of your pain. Be sure to describe to your doctor any positions or activities that make the pain go away, as these can be key clues in coming to a diagnosis.

To test for a CSF leak and determine the location and severity of the leak, several different tests can be performed, although the most accurate non-invasive test is an MRI scan of the brain.

If there is difficulty identifying the exact location of the leak, your doctor may perform an additional test called a CT cisternogram. This requires a spinal tap that injects a contrast liquid into the spinal fluid. It’s followed by a CT scan, which allows doctors to pinpoint the source of the leak and its drainage pathway.

If a CSF leak is not the cause, your doctor may next test for POTS. To diagnose this, your doctor may ask you to participate in a standing test or a tilt table test. Both tests are intended to see if the symptoms of POTS are triggered by your body position.

In a standing test, you’ll be asked to stand upright for 30 minutes, while your doctor monitors your heart rate and blood pressure. In a tilt test, you will lie strapped to a horizontal exam table that tilts your body at varying angles, again while heart rate and blood pressure are closely monitored to see if there is a significant increase.

If both CSF leak and POTS have been ruled out, your doctor will then assess for less common causes such as neck issues, anemia, or brain tumor.

How to Treat a Positional Headache

The approach to treating an orthostatic headache depends on the underlying cause. Treatments range dramatically from at-home remedies and lifestyle changes, to medical procedures and even surgery in more serious cases.

Treating a CSF leak

In some cases, a mild CSF leak will resolve on its own. A person experiencing a moderate CSF leak may try the following at-home remedies to treat orthostatic headache symptoms:

  • Get extra rest, keeping the body lying in a horizontal lying position
  • Stay hydrated by drinking fluids
  • Avoid overexertion (e.g. heavy lifting, strenuous exercise)
  • Limit coughing and sneezing as much as possible
  • Drink coffee, tea, or another caffeinated beverage
  • Eat or drink ginger-based substances to help with nausea
  • Wear an abdominal binder for compression
  • Engage in yoga or meditation

The symptoms of moderate CSF leak headaches may also be treated with:

  • Intravenous (IV) fluid therapy: Someone with a CSF leak may lose more fluids than the average person. A hospital can help replenish those fluids through an IV, which gets essential fluids into the bloodstream more quickly and directly.
  • IV caffeine therapy: Caffeine can also be delivered intravenously at a hospital as a treatment for headaches, particularly following surgery. This may be effective because caffeine stimulates the body’s central nervous system, which influences and increases blood pressure. It’s also thought that caffeine may ease pain during a headache, by constricting blood vessels that have become painfully enlarged.
  • Acupuncture: In some cases, acupuncture has been found to alleviate pain caused by post-dural puncture headaches. A licensed acupuncture practitioner will insert thin needles into the body at specific pressure points, with the goal to stimulate nerves and make them release hormones that may help relieve pain. Acupuncture has mixed results, and its effectiveness is debated by the medical community. Speak with your doctor if you’re interested in trying acupuncture to treat CSF leak headaches.

In the case of a more serious CSF leak, especially if the patient is experiencing chronic or severe positional headaches, a doctor may recommend a procedure called an epidural blood patch (EBP) to give a patient temporary relief of symptoms.

Because the procedure must be done at a medical facility and may have uncomfortable side effects such as back pain, this is generally employed only when other forms of treatment have been ineffective.

An EBP procedure involves injecting 10-100 milliliters of the patient’s own blood into the epidural area of the spinal canal. This serves to patch the outer layer of the meninges, reducing the amount of CSF lost through the membrane. A doctor will either perform the EBP at the location of the leak, or—if the exact location of the leak is unknown—near the middle or lower part of the spine.

While an EBP procedure immediately resolves pain for most people, the effect of the patch does wear off in time, so lasting relief may require ongoing procedures. It’s recommended to avoid bending over and any muscle strain for 4-6 weeks following an EBP.

In the case of a chronic or severe CSF leak, a doctor may recommend various types of surgery to repair structural issues or remove abnormal growths in the spinal region.

Treating POTS

Although there is no cure for POTS, in the majority of cases, symptoms do improve over time with lifestyle changes and medical treatment.

Treatment plans generally include medications and at-home strategies to mitigate the symptoms. Because this condition affects each patient differently, an individual may need to try a few different methods of treatment before finding the one that’s most effective for their body.

If you have POTS, your doctor may prescribe one or more of the following medications:

  • Fludrocortisone: This is a type of corticosteroid that helps your body retain salt and water, both of which are necessary for normal bodily function. POTS often hinders the body from its normal process for balancing bodily fluids, so patients may not retain enough water and salt naturally.
  • Midodrine: This is an alpha-adrenergic agonist that works by tightening the blood vessels, thereby increasing blood pressure as a result. Patients with POTS may be advised to take this medication daily, or when they know they’ll be standing upright for a period of time.
  • Beta-blockers: By stopping adrenaline from reaching the beta receptors in your body, beta-blockers help to lower both heart rate and blood pressure. Since POTS causes unnecessary spikes in heart rate when standing or sitting up, this medication can be helpful for some patients.
  • Selective serotonin reuptake inhibitors (SSRIs): These are antidepressants that help to increase the amount of serotonin that stays circulating in the brain, which can have a relaxing effect on certain body functions, and may help to keep heart rate and blood pressure at reasonable rates.
  • Salt tablets: Another method for helping the body to retain essential levels of salt is to take salt tablets.

The primary approach to treating POTS includes lifestyle changes to manage and lessen the symptoms of this condition. Because people with POTS generally have low blood volume, your doctor may recommend adding more salt to your diet and drinking more water to increase your blood volume.

Other lifestyle changes to help manage POTS include:

  • Drinking about 16 ounces (or two full glasses) of water before standing up
  • Eating smaller meals more frequently to maintain hydration levels
  • Sticking to a regular sleep schedule and get enough sleep
  • Practicing reclined aerobic activities such as biking and rowing
  • Adding salt to your diet (speak with your doctor before doing so)
  • Monitoring symptoms to identify—and avoid—your individual triggers

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How to Prevent Positional Headaches

There is no way to fully prevent positional headaches from developing, as they are generally caused by underlying medical conditions.

However, you may reduce the risks of conditions that cause these headaches by practicing healthy lifestyle habits—such as eating a well balanced diet—and avoiding unnecessary muscle strain.

Risk factors for developing a CSF leak include:

  • Overexerting or straining muscles during physical activity
  • Frequent fits of extreme coughing or sneezing
  • Engaging in activities that jolt or lurch the body around (e.g. roller coasters)
  • Undergoing certain medical procedures, such as a lumbar puncture
  • Genetic or hereditary conditions, including polycystic kidney disease
  • Tumors or cysts in the head, neck, and spine

There is a greater risk of developing POTS in people who:

  • Suffer from an autoimmune condition
  • Have recently experienced mono, or a serious infection or virus
  • Have recently suffered a traumatic head injury
  • Are or were recently pregnant

When to See a Doctor

If you are experiencing unexplained, chronic, or intense headaches, make an appointment with your doctor to discuss your symptoms and rule out any serious causes.

Go to the hospital or seek emergency medical attention if your low pressure headache is accompanied by any of the following symptoms, as these can be warning signs of a CSF leak or POTS:

  • Nausea and vomiting
  • Neck pain
  • Extreme sensitivity to light or sound, hearing loss, or blurred vision
  • Imbalance
  • Pain in between the shoulder blades
  • Dizziness, vertigo, or brain fog
  • Pain or numbness in the arms
  • Extreme fatigue
  • Nipple discharge
  • Sudden changes in heartbeat or blood pressure when standing up
  • Fainting

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How K Health Can Help

Positional headaches are fairly easy to identify.

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K Health articles are all written and reviewed by MDs, PhDs, NPs, or PharmDs and are for informational purposes only. This information does not constitute and should not be relied on for professional medical advice. Always talk to your doctor about the risks and benefits of any treatment.

John Bernard, MD

Dr. Bernard is an emergency medicine physician. He graduated from Jefferson Medical College in Philadelphia, and did his residency in emergency medicine at the University at Buffalo.

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