Trendelenburg Position: A Tool to Screen for the Presence of a Low CSF Pressure Syndrome in Daily Headache Patients

OBJECTIVE: To test the hypothesis that the Trendelenburg position is an accurate screening investigation for the presence of a low cerebrospinal fluid (CSF) pressure syndrome in patients with daily headache. BACKGROUND: The Trendelenburg position causes a rapid increase in intracranial CSF pressure. In a patient with a known CSF leak who overtime had less improvement in the supine position, being placed in Trendelenburg rapidly alleviated her daily headache. This suggested that the Trendelenburg position might be a good screening tool for low CSF pressure syndromes. METHODS: Case reports. All patients were placed in the Trendelenburg position (10 degrees -20 degrees head-down tilt) for 5 minutes. A patient was considered to have a positive Trendelenburg test if they experienced complete pain freedom or substantial improvement in baseline head pain in the Trendelenburg position. RESULTS: Case patients are presented for 3 clinical scenarios: Scenario 1: Daily headache with or without a positional component with a positive response to the Trendelenburg position and subsequent evidence of an underlying low CSF pressure syndrome. Scenario 2: Daily headache with a strong positional component but no improvement in the Trendelenburg position and a negative evaluation for a low CSF pressure syndrome. Scenario 3: Trendelenburg position proves the existence of a post-lumbar puncture headache in patients with near-daily headaches. CONCLUSION: The Trendelenburg position appears potentially useful as a clinical tool to screen for the presence of a low CSF pressure syndrome in patients with daily headache.