Long-Term Headache Outcome and Radiological Correlates in Patients With Intracranial Hypotension

Background: Headache is the most common presenting symptom of intracranial hypotension (IH), and it usually has orthostatic features. However, the outcome of IH and the persistence and characteristics of headache are still overlooked. Methods: In this cohort study, patients diagnosed with IH in our institute between 2018 and 2024 were included. Demographical and clinical data, headache characteristics, etiology, type of treatment (epidural blood patch (EBP), surgical or conservative), and MRI findings were collected. We conducted follow-up visits on headache characteristics and the persistence of headache ≥ 12 months of EBP/conservative treatment. Results: Forty-five patients with a diagnosis of IH were included (mean age of 53.0 ± 14.9 years); 35 (77.8%) were diagnosed with spontaneous intracranial hypotension (SIH) and 10 (22.2%) with secondary IH. EBP was performed on 22 patients (48.9%). Headache was the most common symptom at presentation, in 38/45 patients (84.4%), with orthostatic features in 32 (71.1%). Forty-four patients (97.8%) had brain MRI abnormalities. Follow-up visits were conducted after 31.6 ± 15.7 months; 28/41 (68.3%) patients reported headache during the first 12 months, and 22/41 (53.7%) ≥ 12 months. Headache persistence for ≥ 12 months was significantly lower in patients who received EBP (27.3%) compared to those who did not (63.2%) (p = 0.021). Logistic regression showed that receiving EBP was the only factor significantly associated with reduced likelihood of persistent headache for ≥ 12 months (OR = 0.082, 95% CI [0.007,0.903], p = 0.041). Radiological features differed significantly between patients with SIH and those with secondary etiologies. Conclusion: A large proportion of patients with IH continue to experience headache beyond one year; EBP was the only predictor of headache persisting ≥ 12 months.