EAN 2026 | Spontaneous intracranial hypotension: insights from a session at EAN 2026

The session was about intracranial hypotension, which is very important and is a field that has really moved forward in the last decade. We have these patients in the headache clinic who present with a thunderclap headache and different types of headaches, and it is positional. When they are upright, it comes, and when they lie down again, it goes away. So this is a crucial symptom and history that we see in these patients. But over time, it can become less clear. This positional characteristic can disappear, and that’s why many of these patients are neglected and not identified. They are labeled as chronic migraine, chronic new daily persistent headache, or something like that. But it is a type of headache, a type of disorder that we can treat, so we have to identify them. It is a fascinating area where we learn a lot not only about headache but also general physiology and neurophysiology.

The key problem here is to identify it and ask: how did the headache start? This new headache that you present with, did it start more or less abruptly, or how did it develop? And was there this positional feature at the beginning? Then the suspicion is raised, and we have to go to the next step and do some imaging. It is brain imaging with gadolinium because there you can see very specific signs. We call it a Bern score, where we can see enhancement of the meninges, and we can see many different things, including venous congestion. It can mimic other things, such as subdural hematoma, that could be critical, but it is a mimic. But, the signs are very characteristic, and it has been described in this Bern score in this area from Switzerland. Then we take the next step to perform imaging of the spine with fat suppression because then we can see whether there is a leak of CSF somewhere in the spinal canal. Then we are on the right track and can identify the leak, because if you can close the leak, we can cure the patients.

It is really a fascinating area, and it is not only headache. They can also present with dementia-like symptoms, cognitive problems, hearing problems, dizziness, unsteadiness, and ataxia. So it’s many other symptoms that can occur, but the key is how did it start? Very often, it starts very abruptly, and that is the key to moving forward. The sooner we identify it, the better, because the prognosis is much better if we identify early but still go forward, work for it and try to help these patients. Because you can cure them not only from the headache but also from the cognitive problems. They become a different person when they come back. But you have to team up with a good neurologist, a neurosurgeon, and an anesthesiologist because it is teamwork. You have to go to a specialized center where they have expertise in this because it is a learning process. We are working on biomarkers, on how this disease develops, how the prognosis is determined, and how we can identify these patients earlier. That is the key message.

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