Trendelenburg Position: A Tool to Screen for the Presence of a Low CSF Pressure Syndrome in Daily Headache Patients


  • Conflict of Interest: None

T. Rozen, Neurology, Michigan Head Pain and Neurological Institute, 3120 Professional Drive, Ann Arbor, MI 48104, USA.


Objective.— To test the hypothesis that the Trendelenburg position is an accurate screening investigation for the presence of a low cerebrospinal fluid (CSF) pressure syndrome in patients with daily headache.

Background.— The Trendelenburg position causes a rapid increase in intracranial CSF pressure. In a patient with a known CSF leak who overtime had less improvement in the supine position, being placed in Trendelenburg rapidly alleviated her daily headache. This suggested that the Trendelenburg position might be a good screening tool for low CSF pressure syndromes.

Methods.— Case reports. All patients were placed in the Trendelenburg position (10°-20° head-down tilt) for 5 minutes. A patient was considered to have a positive Trendelenburg test if they experienced complete pain freedom or substantial improvement in baseline head pain in the Trendelenburg position.

Results.— Case patients are presented for 3 clinical scenarios: Scenario 1: Daily headache with or without a positional component with a positive response to the Trendelenburg position and subsequent evidence of an underlying low CSF pressure syndrome. Scenario 2: Daily headache with a strong positional component but no improvement in the Trendelenburg position and a negative evaluation for a low CSF pressure syndrome. Scenario 3: Trendelenburg position proves the existence of a post-lumbar puncture headache in patients with near-daily headaches.

Conclusion.— The Trendelenburg position appears potentially useful as a clinical tool to screen for the presence of a low CSF pressure syndrome in patients with daily headache.