Diagnostic Approach to Chronic Daily Headache with Torcicollis

Diagnostic Imaging

The American College of Radiology recommends that initial imaging for suspected spontaneous intracranial hypotension (SIH) include both brain and complete spinal imaging with sequences optimized for fluids 1, 2.
Magnetic resonance imaging without contrast is inadequate for this clinical presentation, as it may not identify signs of SIH, including dural enhancement, cerebellar tonsillar descent, and spinal epidural fluid collections 1, 2, 3.
Critical signs to look for in contrast-enhanced MRI include diffuse pachymeningeal enhancement, pituitary gland enlargement, cerebellar tonsillar descent, obliteration of the prepontine cisterns, and spinal epidural fluid collections 3.

The American College of Radiology suggests assessing the positional nature of the headache, as worsening in the upright position and improvement in the supine position is a cardinal feature of intracranial hypotension 1, 2.
Associated symptoms to investigate include nausea, vomiting, photophobia, phonophobia, and focal neurological symptoms that could indicate structural pathology 3, 4.

Spontaneous intracranial hypotension: cerebrospinal fluid pressure can be normal in 20-30% of cases, so normal pressure does not exclude the diagnosis 1, 2, 3.

The American Academy of Neurology recommends topiramate as a first-line treatment for chronic migraine, starting with 25 mg and increasing weekly to 50 mg twice daily 5, 4.
OnabotulinumtoxinA (Botox) is the only FDA-approved therapy specifically for the prophylaxis of chronic migraine, based on large phase III studies 5.

Cognitive-behavioral therapy, relaxation training, and biofeedback are effective in preventing migraine 7, 8, 4.
Progressive muscle relaxation, meditation with abdominal breathing, and guided visualization are also beneficial 9, 4.

The American Headache Society recommends re-evaluation if there is a sudden change in headache pattern, new neurological symptoms, worsening despite treatment, or increased need for medications 9, 4.
Indications for referral to a specialist include uncertain diagnosis, ineffective treatment after 2-3 months, or complex comorbidities 4.