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Clinical Presentation The patient with NDPH presents with headache on most if not all days; the onset is recent and clearly recalled by the patient. The headache usually begins abruptly, but onset may be more gradual; evolution over 3 days has been proposed as the upper limit for this syndrome. Patients typically recall the exact day and circumstances of the onset of headache; the new, persistent head pain does not remit. The first priority is to distinguish between a primary and a secondary cause of this syndrome. Subarachnoid hemorrhage is the most serious of the secondary causes and must be. | Chapter 015. Headache Part 20 Clinical Presentation The patient with NDPH presents with headache on most if not all days the onset is recent and clearly recalled by the patient. The headache usually begins abruptly but onset may be more gradual evolution over 3 days has been proposed as the upper limit for this syndrome. Patients typically recall the exact day and circumstances of the onset of headache the new persistent head pain does not remit. The first priority is to distinguish between a primary and a secondary cause of this syndrome. Subarachnoid hemorrhage is the most serious of the secondary causes and must be excluded either by history or appropriate investigation Chap. 269 . Secondary NDPH Low CSF Volume Headache In these syndromes head pain is positional it begins when the patient sits or stands upright and resolves upon reclining. The pain which is occipitofrontal is usually a dull ache but may be throbbing. Patients with chronic low CSF volume headache typically present with a history of headache from one day to the next that is generally not present on waking but worsens during the day. Recumbency usually improves the headache within minutes but it takes only minutes to an hour for the pain to return when the patient resumes an upright position. The most common cause of headache due to persistent low CSF volume is CSF leak following lumbar puncture LP . Post-LP headache usually begins within 48 h but may be delayed for up to 12 days. Its incidence is between 10 and 30 . Beverages with caffeine may provide temporary relief. Besides LP index events may include epidural injection or a vigorous Valsalva maneuver such as from lifting straining coughing clearing the eustachian tubes in an airplane or multiple orgasms. Spontaneous CSF leaks are well recognized and the diagnosis should be considered whenever the headache history is typical even when there is no obvious index event. As time passes from the index event the postural nature may become less .
