A positional headache is a type of secondary headache, which means that it’s due to an underlying health condition. 

There are two main causes of a positional headache: a cerebrospinal fluid leak or postural orthostatic tachycardia syndrome (POTS). Treatment can vary depending on which condition caused the headache in the first place.

This guide from HealthTap breaks down the symptoms of a positional headache, what causes it, and how it can be treated. 

What is a positional headache?

When someone has a positional headache, they typically first experience neck pain, specifically in the back of the neck, that starts when standing up. The pain tends to subside within 30 minutes of sitting down. If the pain doesn’t diminish within that time, it’s more likely to be a tension headache, a migraine headache, or another form of headache.

A positional headache is also referred to as a postural headache, low pressure headache, or orthostatic headache. 

Some people may even wake up in the morning with a mild headache that gets more painful throughout the day. 

Positional headaches usually cause pain in the back of the head, but in some cases, they can cause pain in the front or sides of the head. 

The pain can range in severity from mild to severe. The pain can be described as throbbing, pounding, aching, or stabbing depending on the individual. The pain usually gets worse when doing strenuous activities, coughing or sneezing, or bending over.

Certain types of headaches, such as migraines, can be confused with postural headaches. One way to tell them apart is to lie down for 30 minutes or more and look for changes in symptoms. If there is still headache pain, then it’s likely not a positional headache. 

What causes a positional headache? 

In most cases, a positional headache results from either a cerebrospinal fluid (CSF) leak or postural orthostatic tachycardia syndrome (POTS). While rare, a few other causes can also lead to a positional headache. 

CSF leak

Cerebrospinal fluid is a liquid that surrounds the brain, preventing it from bumping into the skull. 

The meninges (a type of tissue in the brain) hold CSF in place. If any damage occurs to the meninges, then CSF leakage could occur. These leaks can happen after head or neck trauma, a lumbar puncture (spinal tap), or surgical procedures involving the spine and spinal fluid.

Because CSF cushions the brain, a leak can impact the position of the brain and make it more likely to come into contact with the skull, leading to pain. Standing in an upright position can make the pain much worse by causing even more of a CSF leak. 

Imaging through CT myelography, involving a CT scan and an x-ray, can help determine how damaged the meninges are. A CSF leak can be mild and present no symptoms, or it can be severe and lead to intense pain. 

Postural orthostatic tachycardia syndrome (POTS)

POTS is a condition that interferes with the normal functioning of the autonomic nervous system (ANS). The ANS is responsible for involuntary functions, such as breathing, heart rate, and balancing bodily fluids. 

Someone who has POTS may experience a spike in their heartbeat when switching from a lying position to a standing one. This can lead to side effects including dizziness, lightheadedness, nausea, fatigue, and even headache. 

Researchers are not sure what causes POTS. However, this condition seems to disproportionately affect women. 

Other potential causes

The above conditions are the most common causes of positional headaches. However, there may be other explanations of the condition.

Some people have structural neck issues, which is a group of different conditions that affect the muscles, nerves, and connective tissue surrounding the neck. These abnormalities can cause pain in the neck when standing up, which may radiate to the back of the head. 

People with anemia or any other condition that causes low blood volume may experience a headache as less oxygen reaches the brain when standing up.

Sometimes, something as simple as dehydration can lead to a positional headache. When someone is overly dehydrated, their blood pressure may quickly drop when standing up, leading to a headache. 

How are positional headaches treated?

How a doctor treats a positional headache largely depends on its underlying cause. Treatment can range from lifestyle changes to medical procedures. 

If the cause is a CSF leak

If a CSF leak is mild, it may resolve on its own. Someone with a mild CSF leak can try a few at-home remedies, such as getting extra rest, staying well-hydrated, and avoiding intense physical activity. To keep CSF levels consistent, it might help to remain in a lying position as much as possible until the issue resolves.

If the CSF leak is moderate, then treatment options can include intravenous fluid therapy, which is when a healthcare provider uses an IV to replenish a patient’s fluids. This approach is better than drinking more water and electrolytes alone as it allows fluids to reach the bloodstream directly, immediately.  

To treat the pain of mild and moderate postural headaches, a doctor may recommend pain relieving medications. However, this should not be a long-term solution as it can lead to a condition known as a medication overuse headache. 

For those seeking non-pharmaceutical pain relief, options such as yoga, meditation, and acupuncture may help. 

While a person can try yoga and meditation right at home, acupuncture is an in-office procedure that a licensed acupuncturist will perform. Acupuncture involves the insertion of needles into the body at specific points known as “meridians.” This may help release tension and stimulate the nerves responsible for pain.

If the CSF leak is more serious, then a doctor may call for an epidural blood patch (EBP) to bring symptom relief. An epidural blood patch is usually a last resort because it is an in-office procedure and requires time for recovery.

If the cause is POTS

While there is no cure for POTS, a combination of lifestyle changes and medical treatment may help improve symptoms. 

Because people with POTS often have low blood volume, management for this condition may include adding more salt to food, supplementing with electrolytes, and drinking more fluids. It might also help to get regular exercise, as this can help increase blood circulation. 

Aside from lifestyle changes, doctors might prescribe the following medications to help manage POTS. 

• Fludrocortisone
  This is a type of corticosteroid that helps the body retain water and sodium, which can increase total blood volume. A doctor may recommend taking salt tablet with this medication to increase effectiveness.

• Beta blockers
  This medication works by blocking adrenaline, a hormone that prepares the body to “fight or flight” in response to a threat. It lowers heart rate and blood pressure, which can prevent unnecessary heart rate spikes when standing up.

• Midodrine
  This medication works by stimulating the nerve endings in blood vessels. As a result, it causes blood vessels to tighten, which increases blood pressure. Individuals with POTS sometimes take this medication daily to help keep their blood pressure stable. 

• Selective serotonin reuptake inhibitors (SSRIs)
  These are a type of antidepressants that increase levels of serotonin (a chemical found in the brain). Although serotonin mainly works to improve mood, increasing this neurotransmitter can also help stimulate the tightening of blood vessels, which may raise blood pressure. 

If there is another cause

Some lifestyle changes are helpful for symptom relief from any type of headache. For instance, getting enough high-quality sleep can help stave off inflammation, which can result in a reduction in pain. And, of course, smoking can worsen symptoms of virtually any type of headache, so quitting this habit may bring some relief, too. 

In the case of positional headaches, some other risk factors include straining muscles (especially in the neck), coughing or sneezing frequently, or engaging in activities that jolt the body around. Avoiding these triggers could also help keep headaches at bay.

Finding relief with HealthTap

If you suffer from frequent postural headaches, getting to the root cause is essential for finding effective treatment. 

HealthTap can connect you with a low-cost healthcare provider through our secure online platform. This way, you can get a diagnosis, receive additional information related to your case, and get treatment from the comfort of your own home. 

Make your appointment today to connect with a doctor who can help you get started on your health and wellness journey.