Case 460 · ICHD-3 7.2.2
7.2.2 Cerebrospinal fluid (CSF) fistula headache
- Origin
- Synthetic
- Language
- English — also available in German
- Contributed by
- Imported case — HeadAI synthetic vignettes (de Andrade JBC, da Silva Costa TB, Vasconcelos JL, Lopes TLM, Balsells MD, Cristofolini VL, Querobin SO, Filho FMR. Validation of an AI-based platform for structured diagnosis of headache disorders using ICHD-3 criteria. BMC Neurology 25, 489 (2025). doi:10.1186/s12883-025-04473-1. Dataset: Andrade J. Head.AI Platform. Mendeley Data, V2 (2025). doi:10.17632/4fms6cw2s5.2)
Anamnesis
Identification: Gender/Age: Female, 38 years old.
History: Chronic rhinosinusitis, no history of cranial trauma or previous neurosurgery.
History of Present Illness (HPI): Main symptom: Severe headache for 1 week, with spontaneous onset.
Pain characteristics:
Location: Frontal and occipital.
Character: Pulsatile.
Intensity: 7/10.
Positionality: Markedly worsens in the upright position and significantly relieved when supine.
Associated symptoms:
Clear, unilateral rhinorrhea (right side), intermittent.
Nausea without vomiting.
Postural dizziness.
Physical/Neurological Examination:
General: Stable, prefers supine position.
Neurological: No focal deficits.
ENT: Clear rhinorrhea with Valsalva maneuver.
Complementary Exams:
Cranial MRI: Signs of intracranial hypotension (diffuse meningeal thickening, cerebellar tonsillar descent).
Beta-2 Transferrin in rhinorrhea fluid: Positive.
Dynamic Spine MRI with contrast: CSF leakage at C1-C2.
Report this case — e.g. suspected re-identification risk.