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Low-pressure headache — SCE Neurology MCQ

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HardHeadacheLow-pressure headacheSCE Neurology

A 71-year-old man presented with orthostatic headache after lumbar puncture relieved by lying flat. On examination, there was horizontal diplopia from sixth nerve traction. Initial investigations showed: MRI showed diffuse pachymeningeal enhancement and brain sag. Where is the most likely anatomical localisation?

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Correct answer: C — meningeal and CSF spaces

meningeal and CSF spaces is the best answer because the vignette describes Low-pressure headache: postural headache after dural puncture indicates intracranial hypotension. Frontal-subcortical circuits is plausible in a neighbouring presentation, but the chronology, examination or investigation pattern does not match the key discriminator here. Periventricular white matter and Ventral pons are less appropriate because they would require different localisation, timing or test findings; Subarachnoid space would fit a different syndrome. Clinical pearl: IIH worsens with raised pressure and papilloedema rather than low pressure.

Reference: NICE CG150; BASH headache guidance; BNF