title: Trendelenburg position: a tool to screen for the presence of a low CSF pressure syndrome in daily headache patients.
abstract: 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 degrees -20 degrees 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: From the Michigan Head Pain and Neurological Institute-Neurology, Ann Arbor, MI 48104, USA.
authors.forename: Todd
authors.initials: T
authors.lastname: Rozen
authors.forename: Sahar
authors.initials: S
authors.lastname: Swidan
authors.forename: Robert
authors.initials: R
authors.lastname: Hamel
authors.forename: Joel
authors.initials: J
authors.lastname: Saper
mesh_terms: D000328:Adult; D015170:Cerebrospinal Fluid Pressure / Q000502:physiology*; D005260:Female; D018475:Head-Down Tilt; D006261:Headache / Q000175:diagnosis* / Q000209:etiology*; D006801:Humans; D019585:Intracranial Hypotension / Q000150:complications / Q000175:diagnosis; D008875:Middle Aged