Spontaneous Intracranial Hypotension (SIH) condition arises from a leakage of cerebrospinal fluid (CSF), leading to decreased pressure in the brain and spinal cord. Symptoms often include severe headaches, nausea, and neck stiffness, which can significantly impact daily life.

Dr. Manish Taneja

Neurointervention Specialist, Supreme Vascular and Interventional Clinic

Introduction to Spontaneous Intracranial Hypotension (SIH)

Spontaneous intracranial hypotension is rare and often hard to diagnose. The incidence is seen in 5/100,000 individuals every year in Singapore. It refers to a reduced level of, and pressure in, cerebrospinal fluid. Understanding and recognizing it is key to getting treatment, which typically has good results. SIH can cause severe headaches, often worse when standing, as well as nausea and neck stiffness. But the good news is, there are ways to help manage symptoms and improve your quality of life.  

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SIH Symptoms

Spontaneous intracranial hypotension symptoms are somewhat variable, but the hallmark is a positional headache. The headache worsens when standing up, and improves when lying down, and is typically at the back of the head or base of the skull. However, the headache is not always positional. In some cases it gets worse over the cause of the day. Other symptoms include:

  • Pain and/or stiffness in the neck
  • Nausea
  • Sensitivity to light and/or sound
  • Ringing in the ears
  • Changes in hearing or hearing disturbances
  • Profound fatigue
  • Vertigo
  • Dizziness
  • Headache
  • Tinnitus
  • Photophobia
  • Pain between the shoulder blades or in the upper arms
  • Visual changes
  • Facial numbness or pain
  • Back pain
  • Cognitive impairment
  • Movement disorders

Rarely, the condition can cause severe neurological signs such as ataxia, parkinsonism, dementia, and even coma.


Warning Signs and Risk Factors

There are not typically early warning signs. Symptom onset can be very sudden or gradual, likely starting with a new onset headache. They tend to become worse over time. Some common risk factors include: 

  • Connective tissue disorders
  • Spinal pathologies
  • Bariatric surgery



The primary spontaneous intracranial hypotension cause by a loss of CSF (Cerebrospinal Fluid Leak) through a hole or tear in the dura, the outer layer of the meniges. This holds in the CSF, and when it leaks, the volume reduces. Simply put, SIH results from spinal CSF leakage. In some cases, it may be associated with connective tissue disorders, resulting in a weakness of the spinal dura. Calcified discs and bone spurs of the spine can also cause tears of the dura, so if you have these, you should get treatment and watch for symptoms of SIH. Lastly, SIH can be assoiated with a venous fistula in the thoracic spine. This remains poorly understood.

Note that leaks in the head are not associated with intracranial hypotension. It is also typically not associated with a fall or accident.


Who is Affected by SIH

SIH affects females more than males and, again, is often associated with connective tissue disorders. The female to male ratio is 1.5:1. Most people are diagnosed in their early 40s with the mean age being 42 years old. The most common cause is calficied disks or bone spurs, so SIH is most common in individuals with these issues.



SIH is generally suspected when a positional headache or one that gets worse through the day is experienced, especially after sudden onset. Full diagnosis is done by testing cerebral volume and doing a spontaneous intracranial hypotension MRI or other spontaneous intracranial hypotension radiology to look at the fluid cushioning the brain.

A major differential diagnosis is postural orthostatic tachycardia syndrome (PoTS), which has similar symptoms but a very different cause. An MRI can help differentiate, as can doing an echocardiogram to assess the person’s heart.

Common imaging diagnosis may include:

  • MRI brain with contrast
  • MRI spine with contrast
  • Myelography
  • Nuclear scan


Spontaneous Intracranial Hypotension Treatment Options

If your symptoms are extremely mild, then they may not require treatment. Sometimes the leak will heal and the symptoms resolve on their own. In this case, you might be recommended rest, increased hydration, and caffeine to control your symptoms. You may also be recommended ginger to control nausea and pain management. Conservative treatments include:

  • Bed rest for 7-9 weeks
  • Hydration
  • Analgesics
  • Steroids
  • Caffine

Serious complications are a medical emergency. Coma or paralysis requires urgent treatment. The majority of cases, however, are treated by sealing the leak. The first line approach is a non-targeted epidural blood patch. Blood is taken from a vein in your arm and injected into the spinal cord. The blood forms a seal over the leak. However, this is not permanent in all cases and symptoms may return. If they do, or if the surgeon is concerned relief will only be temporary, other patching procedures might be used, such as fibrin sealant, which is targeted. Alternatively, given the simplicity of the procedure, it may just be repeated when symptoms start to return. Note that non-targeted blood patches are also sometimes used diagnostically. After a seal, you should avoid bending, lifting, and twisting for 4 to 6 weeks. Common invasive treatments include:

  • Epidural blood patches
  • Targeted epidural patching
  • Endovascular treatments
  • Surgery

Surgery is an option if less invasive sealing methods don’t work. This is called duraplasty, and involves opening the area over the leak and stitching the hole closed. Outcomes are typically favorable, even if patching has to be repeated.

If you have been diagnosed with, or suspect you have, spontaneous intracranial hypotension, Dr. Manish Taneja, our neurointervention specailist, at Supreme Vascular and Interventional Clinic can help with spontaneous intracranial hypotension treatment in Singapore. Contact us to schedule an appointment at our specialized brain clinic in Singapore to confirm your diagnosis and discuss your treatment options.

SIH can result in severe headaches and other neurological symptoms. On the other hand, a brain aneurysm is a bulge or weak spot in a blood vessel in the brain. While both conditions can cause headaches, they have different underlying causes and mechanisms. However, it’s essential to note that individuals with a brain aneurysm may also experience headaches, and any new or severe headaches should be evaluated by a healthcare professional to determine the cause.

Brain Aneurysm Resources

Discover brain aneurysm resources that go beyond the basics designed for patients. Understand the meaning of  a brain aneurysm condition, the causes, symptoms, signs, and more. Connect with your brain health.

Put Brain Aneurysm on Your Health Radar


Did you experience the worst headache of your life? Could it be a brain aneurysm that ruptures, which means bleeding in the brain? Thoughts could be racing through your mind. Then what is the difference between unruptured (a weak or thin spot on an artery in the brain that balloons) or ruptured brain aneurysm? If you’re wondering, then the Supreme Vascular and Interventional Clinic is here to help. It’s important to look out for the tell-tale brain aneurysm symptoms, signs, causes, and risk factors.

Dr. Manish Taneja has been performing brain aneurysm treatments since 1995 from surgical clipping to latest minimally invasive procedures. Each patient is unique as is the size and location of the aneurysm. Your brain has different conditions to treat the aneurysm and artery vessel walls of a blood vessel in the brain. This calls for personalised brain aneurysm treatment depending on your symptoms, family, history, medication, and more. A simple CT scan could be just what the doctor ordered and the first step in early detection and prevention of a brain aneurysm. Come in for an easy consultation with our brain aneurysm specialist to be on your health radar.

Other Health Conditions

The Supreme Vascular and Interventional Clinic is your “go-to” facility for various neurointerventional / stroke conditions and treatments. To arrange an appointment with Dr. Manish Taneja, our neurointervention specialist, contact us. You can also call us at (+65) 6904 8084 for a consultation.