Beyond “My head hurts”: when to go further

Intracranial hypotension is caused by cerebrospinal fluid (CSF) leakage through the dural membrane, resulting in orthostatic headache. It may occur spontaneously, iatrogenically, or following trauma, and in pediatric patients it is often associated with connective tissue disorders. We report the case of an 8-year-old boy who, after a fall, developed progressive occipital headache accompanied by vomiting, with a clear relationship to the upright position. Craniospinal magnetic resonance imaging confirmed a CSF leak at the lumbosacral level. Conservative treatment with hydration, caffeine, and analgesia was effective, and the clinical outcome was favorable. Follow-up imaging revealed a Tarlov cyst, considered an incidental finding but possibly involved in the CSF leak following trauma. The syndrome is explained by brain displacement and secondary vascular dilation due to CSF loss, leading to pain. Craniospinal MRI is the key diagnostic modality. Initial management is conservative, reserving epidural blood patch therapy for refractory cases. Tarlov cysts are CSF-filled sacs that are generally asymptomatic but may cause neurological symptoms if they compress neural structures. Their origin is uncertain, either congenital or traumatic, and treatment varies according to symptomatology, ranging from medical management to surgery.