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Keywords:

  • Chiari malformation;
  • MR myelography;
  • pachymeningeal enhancement;
  • postural headache;
  • spontaneous CSF leak

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Two patients with cerebrospinal fluid (CSF) leak, one at the level of fourth thoracic spine and another with undetermined level of leak, presented with paradoxical postural headaches in that the headaches were present when in a horizontal position and resolved if the patients were upright. One patient improved spontaneously and the other responded to a targeted epidural blood patch. Paradoxical postural headache is yet another headache type that can be associated with CSF leak and CSF volume depletion. Its mechanism is uncertain, but it could be related to  congestion  and  dilatation  of  cerebral venous sinuses and large veins.