Introduction: In-office use of the Trendelenburg position has been shown to be a beneficial clinical tool to help decipher if a CSF pressure/volume component is part of the underlying etiologic process for a patient’s persistent headache. Utilizing the Trendelenburg position at home could potentially be an additional diagnostic tool for the treating headache physician. Case Series: Our headache practice has been using at-home self-Trendelenburg for the past 2 years and will present the clinical scenarios in which it seems to be the most helpful utilizing a case series of patients. These include (1) in those who just had a lumbar puncture and call for worsening headaches and do not have an obvious orthostatic component; (2) in those who had a spinal epidural blood patch for a presumed CSF leak and state there was no improvement; (3) in those who are on daily preventive CSF volume-lowering medications and call in with worsening headaches; (4) in those with known CSF pressure-dependent headaches high or low but who are not on daily preventive CSF volume modulatory medications; (5) in those with a history of migraine or other primary headache disorder to see if a new type of headache is possibly from a CSF leak or an abnormal reset of CSF pressure to an elevated state; (6) in those with triggered only headaches like cough or exertional headache. Conclusion: Utilizing at-home self-Trendelenburg can provide valuable information for the treating headache physician on possible underlying headache etiology and can guide specific treatment strategies. Its simplicity and quick declaration of results are very patient pleasing.

Utilization of the Trendelenburg position as part of the in-office evaluation of headache patients to help decipher if a cerebrospinal fluid (CSF) pressure/volume component is involved in the pathogenesis of an individual’s daily persistent headache has been noted previously in the literature [1, 2]. In essence, the Trendelenburg position almost instantaneously increases intracranial pressure (ICP); thus, if a patient’s headache improves in this position, they most likely have low CSF volume, and if their headaches significantly worsen, then they are presumed to have elevated CSF pressure [1, 3, 4]. The author has published multiple reports utilizing the Trendelenburg position as an in-office clinical/diagnostic tool especially in patients with a diagnosis of new daily persistent headache [1, 2, 5, 6]. The use of at-home self-Trendelenburg for headache patients has not been previously studied.

The headache specialist and neurologists and general practitioners are constantly tasked to treat their patients from home when they call into the clinic for worsening headaches. Without being able to physically exam the patient in most circumstances, the ability to determine the cause of this new significant headache is difficult especially in those patients who have been doing well on treatment, rarely get periods of headache exacerbation, are not well known to the treating physician, and/or present with a new headache altogether. Without knowing cause can make treatment recommendations difficult and may lead to less effective therapy as treating the underlying etiology of head pain provides more efficacy than treating everything as status migraine for example. Of course, medications like corticosteroid tapers or bursts of ketorolac may break a headache cycle but how they are working and more importantly what happens if cycles recur can be problematic. Thus, to try and achieve a clinical advantage we have been utilizing self-Trendelenburg/self-tipping at home to help establish if at least a CSF pressure/volume component may be playing a role in those individuals’ new or worsening headaches. The goal of this manuscript is to present a possible new diagnostic/clinical tool for treating headache physicians. It is a presentation of clinical observations in a case series of patients that may help in everyday medical practice.

For the last 2 years, the author and his clinic team have been utilizing home self-Trendelenburg for patients who call into the office with a period of headache exacerbation and/or a new headache. The nurses send the patient an email tutorial about self-tipping and what the Trendelenburg position is, but in essence the patients lay on their bed in a supine position and put one or two regular-sized pillows under their legs. They then place their shoulders at the edge of the bed and slightly lean their head over the side of the bed to simulate what is done on a mechanized table in the clinic (Fig. 1). They can have no contraindications to the maneuver such as an intracranial lesion with mass effect, known intracranial hypertension, significant cardiac or pulmonary problems, recent neck or head surgery, and/or cervical or back issues that would not allow this type of positioning.

Fig. 1.

Photograph demonstrating the position for self-Trendelenburg (self-tip) at home. The individual lays supine on the bed with both legs elevated on one or two regular-sized pillows and having shoulders at the edge of the bed and their head hanging slightly over the side of the bed. This position is maintained for a maximum of 2 min.

Fig. 1.

Photograph demonstrating the position for self-Trendelenburg (self-tip) at home. The individual lays supine on the bed with both legs elevated on one or two regular-sized pillows and having shoulders at the edge of the bed and their head hanging slightly over the side of the bed. This position is maintained for a maximum of 2 min.

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They are provided the following instructions: “We are looking to see what your headache and/or head pressure does after being in this position for 1–2 min. If your head pain and pressure get very intense very quickly, then please do not hold that position for the entire 1–2 min.

After completing the test, please report back with your findings. Please write down your pain/pressure levels before, during, and after the testing.

  • 1.

    Baseline headache and/or pressure feeling before getting into the Trendelenburg position? Include pain/pressure score if possible (0–10 on visual analog score).

  • 2.

    What was your immediate response to getting in the Trendelenburg position? (Better, Worse, Neutral) Include pain/pressure score if possible (0–10).

  • 3.

    What was your response to being in the Trendelenburg position for 1–2 min? (Better, Worse, Neutral) Include pain/pressure score if possible (0–10).

  • 4.

    What was your response to getting out of the Trendelenburg position and back into your baseline position? (Better, Worse, Neutral) Include pain/pressure score if possible (0–10).”

We try to have the patient repeat the position several times over a day before communicating back to prove reproducibility of response. Many of the patients have already experienced the Trendelenburg position during their initial consultation visit with the headache specialist in our clinic; thus, they have a good sense of what we are looking for. However, the way we broach the response is by stating “that all individuals will get some form of head pressure sensation when they are in the head-down tilt position. We want them to not focus on that sensation but their present headache and if indeed that headache improves, worsens, or is neutral in the self-tip position.” What we are looking for is some definitive response such as “my headache completely went away or was much improved” suggesting a state of low CSF volume (although other possibilities that can cause improvement include underling systemic hypotension, postural orthostatic tachycardia syndrome, and/or cervicogenic issues such that the Trendelenburg position acts as a neck traction maneuver) or that “my headache got immediately worse or progressively severe and I could not stay in the position” which suggests their CSF pressure is on the higher side (less likely causes are cervicogenic issues with facet irritation and or sinus-based issues with sphenoid irritation or a nasal contact point) or finally “it really did not make much of a difference for me,” thus suggesting at least for the present headache that CSF volume/pressure is probably not playing a part in the underlying etiology.

For clarification in the classic Trendelenburg position, the body and head are straight on the same linear axis whereas in the head-down tilt position the neck is extended while the body remains straight [3]. In our positioning of the patient at home with legs on pillows and head over the side of the bed, we try to mimic true Trendelenburg although there is some head-down tilt involved. Both of these positions have been shown to increase ICP [7, 8]. It has been noted in normal, non-neurologic patients that the rise in ICP with the Trendelenburg position tends to linger even after the patient resumes an upright posture which seems to mimic what we see in the clinic that the worsening or improved headache remains when coming out of the tipped position for several minutes [4]. It is important to note this is a very mild/slight angle Trendelenburg position, not the steep/maximum angle Trendelenburg utilized in gynecologic surgeries which carries a much higher risk of complications including airway edema, respiratory and cardiac issues as well as ocular complications including vision loss [9]. Over the 10 plus years, the author has utilized mild Trendelenburg in the office for durations much longer than is suggested for home use there has never been a complication noted.

What has been noted from our clinical observations is that there are multiple scenarios in which the at-home self-Trendelenburg test can be helpful to the physician to determine the possible cause of a worsening headache. The following are these clinical scenarios with representative case patient examples that have been collected over the past 2 years (Table 1).

Table 1.

Clinical scenarios with self-Trendelenburg response and treatment recommendations

Trendelenburg response
ScenarioImproveWorsenNeutral
1. Post-lumbar puncture Increase fluid and caffeine intake Investigate for possible cerebral vein thrombosis Treat baseline headache disorder 
Consider epidural blood patch 
2. Post-epidural blood patch Consider repeat epidural blood patch Treat with CSF volume-lowering medication Treat baseline headache disorder 
3. On preventive CSF volume-lowering medications with worsening headache Lower daily dose of medication Increase daily dose of medication Look for other secondary causes 
4. Not on preventive CSF volume-lowering medications with worsening headache Look for new or recurrent CSF leak Short course of CSF volume-lowering medication Look for other secondary causes or treat patient’s other primary headache syndrome 
5. New type of headache in patient with other primary headache Look for new CSF leak or other causes of low CSF/blood volume Look for secondary causes of elevated CSF pressure, and evaluate for papilledema Use protocols to break status primary headache disorder 
6. Triggered only headache Neuroimaging: look for CSF leak (brain and spinal cord) Neuroimaging including brain and cerebral venous studies. Treat with CSF volume-lowering medication Neuroimaging: look for other secondary causes 
Trendelenburg response
ScenarioImproveWorsenNeutral
1. Post-lumbar puncture Increase fluid and caffeine intake Investigate for possible cerebral vein thrombosis Treat baseline headache disorder 
Consider epidural blood patch 
2. Post-epidural blood patch Consider repeat epidural blood patch Treat with CSF volume-lowering medication Treat baseline headache disorder 
3. On preventive CSF volume-lowering medications with worsening headache Lower daily dose of medication Increase daily dose of medication Look for other secondary causes 
4. Not on preventive CSF volume-lowering medications with worsening headache Look for new or recurrent CSF leak Short course of CSF volume-lowering medication Look for other secondary causes or treat patient’s other primary headache syndrome 
5. New type of headache in patient with other primary headache Look for new CSF leak or other causes of low CSF/blood volume Look for secondary causes of elevated CSF pressure, and evaluate for papilledema Use protocols to break status primary headache disorder 
6. Triggered only headache Neuroimaging: look for CSF leak (brain and spinal cord) Neuroimaging including brain and cerebral venous studies. Treat with CSF volume-lowering medication Neuroimaging: look for other secondary causes 

In Those Individuals Who Just Had a Lumbar Puncture and Call for Worsening Headaches

The self-Trendelenburg is helpful if the patient cannot define a positionality to this worsening headache in which case the cause is easily identified as a post-procedural CSF leak. If indeed this is a post-lumbar puncture low CSF volume headache, it should improve in the Trendelenburg position, and if it is a neutral response, it may just be an exacerbation of their typical baseline headache. If the patient’s headache worsens however in self-tipping after a lumbar puncture, then the treating physician should consider imaging for a cerebral vein thrombosis [10].

Patient Example

A 34-year-old man diagnosed with new daily persistent headache and a possible elevated CSF pressure component (slightly worse in the Trendelenburg position in the office and having fleeting improvement with acetazolamide and methazolamide) underwent a lumbar puncture to help decipher if indeed CSF pressure was involved in the pathogenesis of his persistent headache. With CSF volume removal (opening pressure 18 cm H2O and closing pressure 13 cm H2O with 9 cc removed), he initially felt worse but then had improved headache intensity for several days. However, he then began to experience a worsening headache that sometimes improved laying supine but definitely worsened with Valsalva. He was instructed to utilize home self-Trendelenburg and found that his headache improved so an epidural blood patch was suggested but the patient wanted to monitor for several more days before having the procedure. His headache intensity stayed elevated but with some slight improvement, so he repeated self-Trendelenburg, and this time the response was neutral. He was instructed to take his typical abortive medication (eletriptan), and this brought his headache back to his normal baseline intensity. Repeat self-Trendelenburg a day later again noted a neutral response suggesting his post-lumbar puncture headache was gone and he was back to his baseline daily persistent headache. The at-home head-down tilt test helped avoid an epidural blood patch which can cause patient morbidity as well as being quite painful.

In Those Who Have Just Had a Spinal Epidural Blood Patch for a Presumed CSF Leak and State There Was No Improvement in Their Headache Post-Procedure

The self-Trendelenburg has been very helpful in deciphering which patients did not improve with the blood patch (better in self-tip) versus those who actually did improve and now are in a state of rebound intracranial hypertension (worse in self-tip), but still presenting paradoxically with head pain improvement laying supine, thus causing the patient to believe they are still leaking.

Patient Example

A 34-year-old woman developed a severe positional headache after a lumbar puncture. She had an epidural blood patch after failing conservative measures. The next day, she related that her headache was still present and was only improved by laying completely flat. She was instructed to try self-Trendelenburg at home and noted an immediate worsening of her head pain. She was diagnosed with rebound intracranial hypertension, and after 3 days of low-dose acetazolamide, the headache abated and repeat self-tip noted a neutral response.

This paradoxical scenario has occurred many times in our practice, and the at-home testing helped prevent sending the patient back for a second epidural blood patch which would have in essence worsened their condition because they were already in a state of elevated CSF pressure. The self-tip results allow the medical staff to correctly treat with a CSF volume-lowering medication to improve the situation. It is very interesting and not well documented in the literature how an effective epidural blood patch, even with rebound intracranial hypertension, can still present in the first few days as a headache that improves laying supine.

In Those Who Are on Daily Preventive CSF Volume-Lowering Medications and Call in with Worsening Headaches

At-home self-tipping can help establish if the patient needs to increase their current dose of medication (worse in Trendelenburg) or needs to lower it as they have actually overshot their CSF pressure and now are in a low CSF volume state. These individuals would note the self-Trendelenburg made their headaches better.

Patient Example

A 58-year-old woman with a daily persistent holocranial pressure headache from onset and whose headaches immediately worsened in the Trendelenburg position was found to have spinal epidural venous congestion from left renal vein compression. After lumbar vein coil embolization, her headaches ceased. She remained on acetazolamide post-procedure, and after several weeks, her headaches returned. Her dose of acetazolamide was increased, but her headaches did not improve and maybe slightly worsened. She was instructed to try self-Trendelenburg (which in the past always worsened her headaches), and this time, her headaches improved suggesting that the diuretic was causing her CSF pressure to go too low for her. She began a medication taper, her headaches resolved (denoting the lumbar coil embolization was successful), and she was able to completely stop the acetazolamide.

In Those with Known CSF Pressure-Dependent Headaches High or Low but Who Are Not on Daily Preventive CSF Volume Modulatory Medications

Patient Example

A middle-aged woman with a history of hypermobile Ehlers-Danlos syndrome, episodic long duration migraine, and both elevated CSF pressure-dependent headaches (found to have underlying nutcracker physiology with spinal epidural venous congestion) and headaches from CSF hypotension (caused by an underlying CSF-venous fistula) would readily utilize home self-Trendelenburg during prolonged periods of headache exacerbation to help guide her headache physician on possible treatment. If she was worse in the self-tip, she would utilize a short course of acetazolamide to get her out of her headache exacerbation period. However, if she improved in self-Trendelenburg, it meant a possible recurrence of her left T12–L1 CSF-venous fistula and that would require repair. This had occurred on two occasions so far. Her quality of life greatly improved utilizing the at-home technique, whereas prior to employing it her severe headaches could go on unabated for weeks at time as the cause of the headache was not being treated.

In Those Individuals with a History of Migraine or Other Primary Headache Disorder to See if a New Type of Headache Is Possibly from a CSF Leak or from an Abnormal Reset of CSF Pressure to an Elevated State

Patient Example 1

A 43-year-old man who had been followed in the headache clinic for 5 years had a change in his headache. When he initially presented, he had developed a daily persistent headache out of the blue without a triggering event. At his initial visit, he worsened in the Trendelenburg position but also had significant upper cervical facet irritation including at the C1–2 level. Neuroimaging including MRI brain, MR angiography head and neck, MR venogram, and MRI cervical spine did not disclose the cause of his headaches although he had significant cervical arthritis and facet arthropathy noted. Lumbar puncture with an opening pressure of 22 cm H2O and with 20 cc of CSF volume removed did not change his headaches. He eventually improved in headache intensity with a C2 dorsal root ganglion rhizotomy combined with serial onabotulinumtoxinA injections and suboccipital nerve blocks although he still had a persistent daily headache which never responded to a multitude of preventive medications. Several years later, he began to develop worsening headaches and was unsure if it was his long-lived baseline headache or something new. He did relate he was on a trip and found this “new” headache improved when he went scuba diving. As scuba diving could conceivably raise his CSF pressure, he was instructed to try self-Trendelenburg at home. In this case, he chose to use a gravity table and he became headache free while in the downward position. He ended up using the inversion table on a near-daily basis, and he would stay in the downward position for several hours a day as he felt so much better in it and much worse upright. Repeat neuroimaging including an MRI brain and an MR heavily weighted T2 myelogram of the entire spine did not demonstrate findings suggestive of CSF hypotension and did not identify a spinal fluid leak site. Because of the improvement in self-Trendelenburg, he underwent a CT-guided interlaminar T3–4, T7–8, L1–2 epidural fibrin glue and blood patch procedure with significant improvement in the headache such that he no longer needed self-tipping at home. This suggested that he had developed a new CSF leak on top of his primary daily persistent baseline headache. The cause of his presumed CSF leak was likely from a bone spur although a CSF-venous fistula was also considered.

Patient Example 2

A woman in her 60s with a long history of chronic migraine well controlled with onabotulinumtoxinA began to develop sleep-associated headaches. These would awaken her about 90 min after falling asleep. They felt like severe holocranial head pressure and were not reminiscent of her prior migraines. The headache seemed to become worse if she would continue to lay flat and possibly improved after getting out of bed or naturally improved over several hours. They would occur 3–4× per week and lacked any migrainous-associated symptoms. She denied any triggering event for these headaches. There was no recent weight gain; in reality, she was underweight her entire life. She had hypermobile Ehlers-Danlos syndrome. The differential included hypnic headache, cervicogenic-based pain, obstructive sleep apnea (she never snored), and possibly an elevation of CSF pressure. She was instructed to try self-Trendelenburg during the acute headaches, and this consistently caused the head pain to worsen, suggesting that while she was sleeping her CSF pressure was rising above her head pain threshold point. Acetazolamide at bedtime was prescribed, and this essentially eliminated the sleep-associated headaches. Eventually, she was diagnosed with nutcracker physiology with spinal epidural venous congestion, and after lumbar coil embolization, her sleep-associated headaches completely were abolished off any medication. This case has been recently presented elsewhere focusing on the unique headache presentations of nutcracker physiology, but it was the self-Trendelenburg test that helped lead to the discovery of its underlying secondary etiology [11].

In Those Individuals with Triggered Only Headaches Like Cough or Exertional Headache

Valsalva-based headaches can indicate a state of intermittent high or low CSF pressure so the self-Trendelenburg is uniquely qualified to help answer that question [5]. These triggered headaches also require neuro-imaging looking for secondary underlying causes. The studies ordered can be better determined by the response to Trendelenburg positioning, such as the need of brain and spinal cord evaluation if the patient improves in self-tipping (presumed CSF leak) and the need for additional venous imaging, looking for cerebral vein thrombosis or transverse sinus stenosis, if the patient worsens in Trendelenburg.

Patient Example

A man in his early sixties presented with an 18-month history of headaches triggered only by exertion and/or Valsalva maneuvers. The headaches would be located at the vertex and back of his head. If he would lay down, they would dissipate in 20 min. If he remained upright, the headaches would worsen, and he would vomit. No medication had helped him including pretreating exertion with indomethacin and the use of topiramate. His neuroimaging showed some possible signs of intracranial hypotension such as low-lying cerebellar tonsils, but he also had a partial empty sella suggesting elevated CSF pressure. There was no pachymeningeal enhancement. During his consultation visit, he was placed in the Trendelenburg position, and he developed a slight increased head pressure discomfort, but he did not have his exertional headache at the time. The thought was that maybe he was in a state of elevated CSF pressure and the Valsalva pushed his CSF pressure above the head pain-inducing threshold point. He was instructed to try self-tipping at home during his exertional headache, and the headache immediately ceased in this position. He repeated the maneuver with a subsequent headache with the same response. As he improved with increased CSF volume during the head-down tilt, he was then investigated for a presumed intermittent CSF leak. On dynamic CT myelography, he was found to have a left thoracic (T8) CSF-venous fistula which was embolized. He is now completely headache free with exertion with long-term follow-up.

The CARE Checklist has been completed by the author for this case series, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000539615).

Limitations

These are observational results alone so further evaluation with more stringent criteria is needed to help substantiate the findings. Not all improvement or worsening in the Trendelenburg position is CSF pressure dependent so false positives and negatives may exist. Reproducibility in the clinic on a mechanized table after the at-home observations has been completed in a number of our patients and is helpful to confirm the results as the at-home test is not classic Trendelenburg by physical parameters.

Utilizing at-home self-Trendelenburg can provide valuable information for the treating headache physician on possible underlying headache etiology and can guide specific treatment strategies without the need for immediate in-person evaluation. Its simplicity and quick declaration of results are very patient pleasing. At-home self-Trendelenburg should be considered a new diagnostic/clinical tool for those in the medical field treating headache patients. At-home Trendelenburg should only be utilized in healthy patients without known contraindications for self-tipping and the subsequent rise of ICP that follows.

The author would like to thank Mr. Lincoln Rozen for demonstrating the self-Trendelenburg position in Figure 1.

Written informed consent was obtained from the patients for publication of the details of their medical case and any accompanying images. This was approved by the Mayo Clinic Institutional Review Board – IRB number: 19-002635.

The author declares that there are no conflicts of interest.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

T.R.: conceptualization, formal analysis, investigation, methodology, and writing – original draft, review, and editing.

No extra data beyond what is available in the presented case series were added to this article. Further inquiries can be directed to the corresponding author.

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