Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension

J Neurol Neurosurg Psychiatry. 2023 Oct;94(10):835-843. doi: 10.1136/jnnp-2023-331166. Epub 2023 May 5.


Background: We aimed to create a multidisciplinary consensus clinical guideline for best practice in the diagnosis, investigation and management of spontaneous intracranial hypotension (SIH) due to cerebrospinal fluid leak based on current evidence and consensus from a multidisciplinary specialist interest group (SIG).

Methods: A 29-member SIG was established, with members from neurology, neuroradiology, anaesthetics, neurosurgery and patient representatives. The scope and purpose of the guideline were agreed by the SIG by consensus. The SIG then developed guideline statements for a series of question topics using a modified Delphi process. This process was supported by a systematic literature review, surveys of patients and healthcare professionals and review by several international experts on SIH.

Results: SIH and its differential diagnoses should be considered in any patient presenting with orthostatic headache. First-line imaging should be MRI of the brain with contrast and the whole spine. First-line treatment is non-targeted epidural blood patch (EBP), which should be performed as early as possible. We provide criteria for performing myelography depending on the spine MRI result and response to EBP, and we outline principles of treatments. Recommendations for conservative management, symptomatic treatment of headache and management of complications of SIH are also provided.

Conclusions: This multidisciplinary consensus clinical guideline has the potential to increase awareness of SIH among healthcare professionals, produce greater consistency in care, improve diagnostic accuracy, promote effective investigations and treatments and reduce disability attributable to SIH.

Keywords: CSF dynamics; headache; interventional; neuroradiology; neurosurgery.

Publication types

  • Systematic Review

MeSH terms

  • Cerebrospinal Fluid Leak / complications
  • Cerebrospinal Fluid Leak / diagnosis
  • Cerebrospinal Fluid Leak / therapy
  • Diagnosis, Differential
  • Headache / diagnosis
  • Headache / etiology
  • Headache / therapy
  • Humans
  • Intracranial Hypotension* / diagnosis
  • Intracranial Hypotension* / therapy
  • Magnetic Resonance Imaging / adverse effects