Clinical case report: headache due to cerebrospinal fluid hypotension treated with caffeine

Case presentation: A 16-year-old male patient with a previous history of WHO Grade IV Medulloblastoma in the posterior fossa, resected at the age of 14, also submitted to radiotherapy and adjuvant chemotherapy. He sought medical attention referring episodes of headache associated with the orthostatic position, with criteria for hospitalization. Upon evaluation, the patient reported continuous headache, with biparietal and occipital location, associated with fatigue, nausea, dizziness and blurred vision, refractory to analgesia. He presented with ataxia, diplopia and preserved ocular motricity, without other alterations. During hospitalization, brain and neuraxial images showed no relevant changes. Lumbar puncture with spinal manometry showed cerebrospinal fluid (CSF) hypotension, with an opening pressure of 10 cmH2O measured in lateral decubitus, thus establishing the diagnosis of headache due to CSF hypotension. Clinical measures were taken to provide analgesia, with little response. Scintigraphy with cisternography was performed, without signs suggestive of CSF leak. It was decided to associate oral caffeine citrate, at a dose of 200 mg a day, to the drug regimen. Then, the patient reported a progressive decrease in episodes of headache in orthostatism, presenting criteria for hospital discharge and outpatient follow-up. At this time, the patient was instructed to consume coffee during meals, except at night, and anhydrous caffeine was prescribed orally at a dose of 100 mg daily. After that, the patient remained without new episodes of headache until the present moment.

Discussion: The headache due to CSF hypotension is attributed to venodilation compensatory to CSF ​​volume depletion in the brain. Caffeine has been used as part of conservative clinical management because of its vasoconstrictor action, attenuating symptoms attributed to compensatory venous engorgement, although there is a need for studies whose results corroborate its use in clinical practice. The present report has great clinical relevance as it demonstrates a case of headache due to CSF hypotension refractory to analgesia occurring in the absence of significant imaging changes, in which caffeine was used for empirical symptomatic treatment, with therapeutic success.

Final comments: This case report supports the hypothesis that the use of caffeine may represent an important and effective therapeutic option for the clinical management of orthostatic headaches attributed to CSF hypotension.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
18 September 2023