A positional headache is a headache that changes in intensity based on body position, most characteristically worsening when upright and improving when lying down (orthostatic headache).
This pattern typically occurs or intensifies within 15 minutes of standing and subsides within 15 to 30 minutes of lying down.
The classic positional headache is orthostatic, meaning it worsens in the upright position and diminishes after lying down.
The interval between standing and headache onset is typically minutes, though it can range from instantaneous to several hours, including a second-half-of-the-day pattern where the headache develops only after prolonged upright positioning.
The headache usually improves within minutes of becoming supine.
Positional headaches are most commonly associated with intracranial hypotension, either spontaneous or following procedures like lumbar puncture.
The mechanism involves increased CSF efflux in the upright position, leading to traction on pain-sensitive dural fibers and compensatory venous engorgement.
The headache may be diffuse or localized (commonly occipital or suboccipital), and can be throbbing or non-throbbing.
While orthostatic headache is the hallmark presentation, the positional characteristic can become less apparent over time.
Some patients may develop non-positional headache patterns, or rarely experience reverse orthostatic headache.
Associated symptoms often include neck stiffness, nausea, tinnitus, muffled hearing, and photophobia.
Positional headache is a key clinical feature in the differential diagnosis of secondary headaches and warrants evaluation for underlying causes, particularly CSF leaks and intracranial pressure disorders.