Case Study: Positional Headache and Unilateral Rhinorrhea in a Young Woman

Case at a Glance

A 20-year-old female presented to the emergency department with an acute, severe headache followed by the onset of clear, watery drainage from her left nostril. Despite symptoms suggestive of a cerebrospinal fluid (CSF) leak, including a positional headache, she was discharged without imaging. This case highlights the diagnostic challenge of spontaneous CSF leaks and the importance of key clinical signs.

Patient's Story

The patient is a 20-year-old female with a history of migraines who presented after an acute episode at her workplace. She experienced a sudden, severe, 'splitting' headache, describing it as a painful, building pressure in the occipital region. She also reported feeling delirious and nauseous. While bending forward in anticipation of vomiting, she noted a sudden gush of clear, watery fluid from her left nostril. She described the fluid as non-viscous, with a 'metallic' taste. Immediately following this, she experienced temporary blurring of vision in her left eye. The headache's intensity subsided after the drainage.

Initial Assessment

The patient presented to the emergency department (ED). The attending physician acknowledged the possibility of a CSF leak but was skeptical due to the absence of recent head trauma, stating that spontaneous leaks are rare. He suggested the rhinorrhea was likely related to sinus drainage from seasonal allergies, a condition the patient denied ever having. The patient's description of the headache as being distinct from her typical migraines was noted but not pursued further. She was treated with intravenous antiemetics and diphenhydramine for symptomatic relief, which resulted in sedation. No fluid was collected for analysis, and no imaging was ordered. She was discharged with a diagnosis of 'headache' and instructed to return if she developed a 'thunderclap headache' or fever, citing the risk of meningitis.

The Diagnostic Journey

Over the two days following her ED visit, the patient's symptoms persisted, albeit with less severity. She experienced morning headaches and continued intermittent, clear drainage from the left nostril. She reported significant lethargy, requiring 14-16 hours of sleep per day. When asked about postural components, the patient confirmed her headache was significantly worse when she was upright and relieved by lying down—a classic sign of intracranial hypotension. She attempted a 'halo sign' test at home on absorbent paper, noting the fluid dried without the shiny residue characteristic of mucus. The differential diagnosis included a simple viral upper respiratory infection (given the headache and lethargy), vasomotor rhinitis, or a spontaneous CSF leak. The patient's report of a positional headache strongly elevated the clinical suspicion for a CSF leak, which can occur spontaneously, sometimes in the context of underlying connective tissue disorders or conditions of high intracranial pressure (e.g., Idiopathic Intracranial Hypertension - IIH).

Final Diagnosis

Suspected Spontaneous Cerebrospinal Fluid (CSF) Leak. The combination of acute-onset severe headache relieved by fluid discharge, persistent unilateral clear rhinorrhea, a metallic taste, and a prominent positional headache makes a CSF leak the leading diagnosis until proven otherwise.

Treatment Plan

Given the high suspicion for a CSF leak, the recommended plan is an urgent outpatient follow-up with Otolaryngology (ENT) and/or Neurology.

1. Confirmation: The patient should be instructed on how to collect a sample of the nasal fluid for beta-2 transferrin analysis, which is highly specific for CSF.
2. Localization: High-resolution CT of the skull base and sinuses is the first-line imaging modality to identify a potential bony defect. If negative, a CT or MR myelogram may be necessary to locate the site of the dural tear.
3. Conservative Management: While awaiting workup, the patient should be advised to begin conservative treatment, including strict bed rest, hydration, and caffeine intake to increase CSF production and lower the pressure gradient at the leak site.
4. Intervention: If the leak does not resolve with conservative management, an epidural blood patch may be considered. For persistent or identified structural leaks, surgical repair by an ENT or neurosurgeon would be indicated.

Outcome and Follow-up

The patient was discharged from the ED without a definitive diagnosis or workup. The subsequent identification of a positional headache is a critical piece of information that mandates further investigation. The immediate priority is specialist referral to confirm the diagnosis and identify the source of the leak to prevent complications, most notably bacterial meningitis. This case underscores that a spontaneous CSF leak should remain on the differential for patients presenting with new-onset headaches and rhinorrhea, even without a history of trauma, particularly when classic postural symptoms are present.