Headache When Standing Up: Causes, CSF Leak and Blood Patch

Headache When Standing Up — Low-Pressure Headache, CSF Leaks and the Blood Patch

Why a headache can come on when you stand and ease when you lie down, what causes it, how a blood patch works, and the warning signs that need urgent care. Explained by a Sydney neurologist.

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Headache When Standing Up: When It Needs Urgent Care

Most headaches that come on when you stand are not dangerous. A few patterns need care straight away, so they come first.

Call 000 — or go to an emergency department — if

a headache comes on suddenly and severely and reaches its worst within a minute (the worst headache of your life), even if it then eases
a sudden, severe headache comes on when you change position, such as sitting up, standing or bending, with fainting, collapse or unusual drowsiness, even if a similar attack has passed before
a very high blood pressure reading (a top number of 180 or more, or a bottom number of 120 or more) comes with chest or back pain, shortness of breath, vomiting, problems with your eyesight, confusion or a seizure: call 000 straight away
your blood pressure is still very high when you measure it again after 5 minutes of sitting quietly, and you have a headache
the headache comes with fever and a stiff neck, a rash that does not fade when pressed, confusion or unusual drowsiness
you are over 50 with a new headache, or a change in your usual headaches, and you notice blurring, double vision, or sight that dims or goes dark in one eye, even if it lasts only a few minutes
the headache comes with sudden loss or dimming of vision (even if brief), double vision, a new drooping eyelid or one pupil larger than the other, slurred speech, sudden severe dizziness or unsteadiness, or numbness, weakness or drooping of the face, an arm or a leg
an eye becomes painful and red, with blurred vision, halos (coloured rings) around lights, or nausea and vomiting
the headache started after a head injury and is getting worse, comes with vomiting, drowsiness or confusion, or you take blood-thinning medicine
after a head injury, clear fluid or blood comes from your nose or an ear
after a lumbar puncture, an epidural or spinal anaesthetic, or a blood patch, you have new numbness or weakness in your legs (or numbness from an epidural that does not wear off as expected), numbness around your bottom or genitals, trouble passing urine or controlling your bladder or bowel, or severe or increasing back pain, or new severe pain in a leg: go to an emergency department now
after a lumbar puncture, an epidural or spinal anaesthetic, or a blood patch, you have a fever, or redness, swelling or pus where the needle went in: contact the team that did it straight away, or go to an emergency department now
the headache comes with a seizure
you are more than 20 weeks pregnant or had a baby in the last 6 weeks and have a severe headache, a headache that does not get better with simple pain relief, blurred vision or flashing lights, sudden swelling of the face, hands or feet, pain under the ribs or in the upper tummy, vomiting with a headache, or a reading of 160/110 or more: go to your maternity unit or an emergency department now; call 000 for a seizure, trouble breathing or chest pain
you have a spinal cord injury at mid-chest level or higher and get a sudden, pounding headache, often with sweating or flushing above the injury: sit upright with your legs down, loosen anything tight, check your bladder, catheter and bowel, and follow your own dysreflexia plan if you have one; call 000 if it does not settle within a few minutes or you cannot find the cause

A sudden, explosive headache, wherever it is felt, can mean bleeding around or into the brain (a subarachnoid or intracerebral haemorrhage); a spinal fluid leak can also start suddenly, and only tests can tell them apart. A sudden, severe headache brought on by a change of position, with fainting or drowsiness, can mean a rare fluid-filled cyst deep in the brain (a colloid cyst) is suddenly blocking the flow of fluid, which is life-threatening. A very high reading with chest or back pain or shortness of breath can mean the heart or the main artery from the heart is under strain; with vomiting, problems with eyesight, confusion or a seizure, it can mean the pressure is affecting the brain (hypertensive encephalopathy). A very high reading with a headache needs checking in an emergency department, because only tests can show whether the pressure is harming the brain, heart, eyes or kidneys. In someone over 50, a new headache with a change in vision can mean giant cell arteritis is cutting off the blood supply to the eye: treated the same day, sight can usually be saved, but sight that is lost rarely comes back. Weakness, numbness or drooping of the face, trouble speaking, sudden unsteadiness or a sudden loss of vision can mean a stroke. Double vision, a new drooping eyelid or a change in the size of one pupil can mean pressure on a nerve from a bulging blood vessel (an aneurysm) or a tear in the wall of an artery in the neck (a dissection). A painful red eye with blurred vision and halos can mean a sudden rise in the pressure inside the eye (acute angle-closure glaucoma), which can permanently damage sight if it is not treated quickly. After a head injury, bleeding inside the skull can build up over hours, sometimes after a spell of feeling well, and clear fluid or blood from the nose or an ear is a sign of a severe head injury. New numbness or weakness in the legs, numbness around the bottom, trouble with the bladder or bowel, or severe back or leg pain after a procedure on the spine can mean bleeding or an infection is pressing on the nerves in the spine, which needs urgent treatment; a fever, or redness, swelling or pus where the needle went in, can mean an infection, which needs checking straight away. Fever with a stiff neck, or a rash that does not fade when pressed, can mean meningitis; a stiff neck without a fever is common with a spinal fluid leak. A seizure with a headache needs urgent checks for a cause in the brain. In pregnancy or after a birth, a severe headache can be the first sign of pre-eclampsia, a condition of high blood pressure in pregnancy that can lead to seizures; after a birth, a headache that is worse when you sit or stand is often from the epidural, but not every headache after a birth is, so a severe one goes to the maternity unit or an emergency department now, whatever its pattern. After a spinal cord injury, a pounding headache can be autonomic dysreflexia, a sudden surge in blood pressure set off by something below the injury, such as a full bladder. In both, lower readings than 180/120 count: in pregnancy, 140/90 is high and 160/110 is severe; after a spinal cord injury, a rise in the top number of 20 to 40 or more above your usual reading matters, and 130/90 can already be high. All need urgent treatment. If you have migraine, your usual aura (shimmering or zigzag lines that spread slowly over several minutes and clear within an hour) does not need 000 on its own, and nor do the eye signs of attacks a doctor has already diagnosed as cluster headache (a red, watering eye, a drooping eyelid or a smaller pupil). A first cluster-like attack, a first aura after 50, or an attack or aura that is different from your usual ones needs an emergency department the same day; call 000 if it comes with a new drooping eyelid, one pupil larger than the other, or a very high reading. In the same way, vomiting in your usual migraine attack does not need 000 on its own; with a very high reading, or any other sign in this list, it does, and if you are more than 20 weeks pregnant or had a baby in the last 6 weeks, vomiting with a headache needs your maternity unit or an emergency department now, even in a usual attack. If a doctor has diagnosed POTS or low blood pressure on standing, your usual light-headedness or dizziness when you stand, which eases when you sit or lie down, does not need 000 on its own; dizziness that is sudden and severe, does not ease when you lie down, or comes with double vision, slurred speech, trouble walking, or numbness or weakness, does, and so does feeling very unwell, or a faint that is not like your usual ones or from which you do not recover quickly and fully. If a doctor has diagnosed a headache from a lumbar puncture, an epidural or a spinal fluid leak, your usual headache that comes on within seconds or minutes of sitting up and eases when you lie down does not need 000 on its own; a sudden, severe headache unlike your usual one, or one with fainting, collapse, drowsiness, confusion or weakness, does. One that is now just as bad lying down as upright, or becomes constant or much more severe, over hours or days, needs an emergency department the same day; with a known leak, lying down helping less and less over weeks or months needs your GP or the doctor treating your leak the same day. Remember FAST: Face drooping, Arm weakness, Speech difficulty, Time to call 000.

See your GP the same day if

a new headache keeps coming on when you sit up or stand and easing when you lie down (after a lumbar puncture, an epidural or a spinal anaesthetic, see the next item)
a headache starts in the days or weeks after a lumbar puncture, an epidural or a spinal anaesthetic and is worse when you sit or stand: contact the hospital or doctor who did the procedure the same day, or your GP; if you had a baby in the last 6 weeks, contact your maternity unit, and for a severe headache, go now (see the list above)
a headache after a lumbar puncture, an epidural, a spinal anaesthetic or a blood patch, or with a known spinal fluid leak, changes over hours or days: it is now just as bad lying down as upright, or becomes constant or much more severe: go to an emergency department the same day; with drowsiness, confusion, a seizure, or weakness or numbness of the face, an arm or a leg, call 000 (after a blood patch, a new headache that is worse lying down and better upright: see the next item); if, with a known leak, lying down has slowly helped less and less over weeks or months, see your GP or the doctor treating your leak the same day, because a scan may be needed
after a blood patch, you have new nausea or vomiting, or a new headache that is worse when you lie down and better when you are upright: contact the team that did it the same day, and if it is severe or keeps getting worse, go to an emergency department the same day (with a fever, or redness, swelling or pus where the needle went in, see the list above)
clear, watery fluid keeps dripping from your nose or an ear, with no cold or allergy to explain it (after a head injury, see the list above)
it is a new headache, or a change in your usual headaches, and you are over 50, especially with a new tender scalp that does not go away, pain in the jaw when you chew that eases when you stop, aching shoulders, or feeling generally unwell; with any change in your vision, see the list above
a new headache on one side, unlike your usual headaches, comes with new pain on the same side of the neck, or with a ringing or whooshing in the ear that started suddenly, especially after a neck injury, a sudden twist or stretch of the neck, or neck manipulation: go to an emergency department the same day; with a new drooping eyelid or one pupil larger than the other, or any other sign in the list above, call 000
a first attack of severe pain in or around one eye or temple, with a red or watering eye or a blocked or runny nostril on that side, or, if you have cluster headache, an attack unlike your usual ones: go to an emergency department the same day; with a new drooping eyelid or one pupil larger than the other, call 000
a rash of small blisters appears on one side of the forehead, temple or scalp, often after 2 or 3 days of burning or tingling pain there; if the rash reaches the tip of the nose, or the eye becomes red, painful or blurred, go to an emergency department the same day
your blood pressure is still very high (a top number of 180 or more, or a bottom number of 120 or more) when you measure it again, even if the headache has gone and you feel well (in pregnancy and after a spinal cord injury, lower readings count: see above)
the headache is getting steadily worse over days or weeks
the headache is worse when you lie down, or is worst on waking and comes with vomiting or blurred vision
the headache is brought on by coughing, sneezing, laughing or straining, or comes with a whooshing sound in the ears in time with your heartbeat (if it started suddenly with a new headache on one side, go to an emergency department the same day: see above)
you have a fever with the headache
it is a new headache, or a change in your usual headaches, and you have, or have had, cancer, or you have a weakened immune system
you are pregnant or have had a baby in the last 6 weeks, or a reading taken from 20 weeks of pregnancy to 6 weeks after the birth is 140/90 or more: contact your midwife, maternity unit or GP the same day; with blurred vision or sudden swelling of the face, hands or feet, contact your maternity unit or go to hospital now

A new headache that keeps coming on when you are upright and easing when you lie down can be a spinal fluid leak, which is easily missed and can lead to bleeding over the surface of the brain, so it is looked into rather than waited out. A headache after a lumbar puncture or an epidural is usually the expected kind, which settles, but the team that did the procedure needs to know, and can offer a blood patch if it is severe. A headache that is now just as bad lying down as upright, or becomes constant or much worse, over hours or days after a puncture or with a known leak can mean a collection of blood over the brain (a subdural haematoma) or a clot in a vein of the brain, which need a scan that day; a slower change over weeks or months can happen as a leak goes on, but a doctor still needs to decide whether a scan is needed. After a blood patch, a new headache that is worse lying down, or new nausea or vomiting, can be rebound high pressure, which usually settles but is treated differently from a leak; nausea or vomiting can also be a sign of an infection, so the team needs to know that day. Clear fluid that keeps dripping from the nose or an ear can be the fluid from around the brain leaking through the skull, rather than the spine, and needs checking. A tear in the wall of an artery in the neck (a dissection) can lead to a stroke in the days after it starts, so it needs a scan of the neck arteries that day. A first attack of severe pain around one eye with a red, watering eye is often cluster headache, but a few conditions that need treatment can look the same, so the first one is checked that day. Shingles near the eye can damage sight, and its treatment works best when it is started early. Some migraine attacks begin on waking with nausea or vomiting; what needs checking is a headache that is worse when you lie down, or a new headache, or a change in your usual headaches, that keeps coming back on waking with vomiting or blurred vision, or one that is getting steadily worse, because these can mean raised pressure inside the head. In someone over 50, a new tender scalp that does not go away, or jaw pain on chewing, can mean giant cell arteritis, an inflammation of the arteries of the head that can threaten sight, so it is checked that day. A headache brought on by coughing or straining can come from a problem at the back of the brain, so it is checked if a doctor has not already looked into it. Fever can mean an infection. Cancer, a weakened immune system, and pregnancy or a recent birth each make some serious causes more likely, so the bar for checking is lower. A very high reading without symptoms is rarely an emergency, but it needs a doctor that day to start or adjust treatment. The other items are explained further down this page. If you cannot see your GP that day, go to an emergency department. If something matches both lists, follow the 000 list.

Where most people sit

These patterns are uncommon. Headaches that come on when you stand often have a common cause: a dip in blood pressure or a fast heartbeat when you stand up, too little fluid, or a recent lumbar puncture or epidural, and that last kind usually settles within a week or two. Spinal fluid leaks that happen on their own are uncommon, about 4 new cases a year in every 100,000 people in two US population studies, and they can be treated.

Why Would Standing Up Give You a Headache?

It often follows the same pattern. You wake feeling almost normal. Within minutes or hours of getting up, a heavy, pulling ache builds in the head or the back of the neck, sometimes with nausea, ringing in the ears or a muffled feeling in them. Lie flat and it eases; get up and it comes back. It is natural to blame poor sleep, a stiff neck or low blood pressure, and to try drinking more water. But why would a headache depend on which way up your head is?

Often the answer is the fluid around the brain. The brain and spinal cord float in a clear fluid (cerebrospinal fluid, or CSF), held inside a tough lining (the dura) that runs from the skull down the spine. The fluid cushions the brain, a little like a water bed. If fluid leaks out through a small hole or tear in the lining in the spine, the amount of fluid and its pressure fall. When you sit or stand, the brain then sits lower in the skull, which is thought to stretch the pain-sensitive linings and blood vessels around it; lying flat takes that pull away. A brain that sits lower than usual (brain sagging) is one of the signs doctors look for on an MRI scan. The international classification of headache disorders, the rulebook neurologists use, calls this a headache attributed to low CSF pressure, and notes that it is usually, but not always, worse upright.

It turns out that a headache that changes this much with posture is one of the more useful clues in neurology, because few headaches do. The main causes are low fluid pressure around the brain, a drop in blood pressure or a racing heart when you stand, and too little fluid in the body. Low fluid pressure most often follows a lumbar puncture, an epidural or a spinal anaesthetic, when fluid leaks through the needle hole for a few days. Less often, fluid leaks from the spine with no procedure at all (spontaneous intracranial hypotension), and this is easy to miss: in one US series, 17 of 18 people were first told they had something else, migraine among the commonest, and the delay to the right diagnosis ranged from 4 days to 13 years.

So the timing is the clue. How soon the headache comes after you get up, how quickly lying flat eases it, whether it began after a procedure, and what comes with it, such as a racing heart, light-headedness, ringing in the ears or neck pain, point to the cause. A normal brain scan does not always rule a leak out, which is why the story matters so much.

Where most people sit

Most people with this pattern have one of the common causes. POTS affects about 2 to 10 in every 1,000 people, mostly young women, and a headache after a lumbar puncture or epidural usually settles on its own within a week or two. Spinal fluid leaks that happen on their own are uncommon, about 4 new cases a year in every 100,000 people, and they can be treated: the usual first treatment, a blood patch, settles the headache for many people, and most improve with treatment, sometimes after more than one procedure.

A Leak, Low Blood Pressure or POTS? How the Pattern Helps Tell Them Apart

A neurologist first asks how the headache behaves when you get up and when you lie down, because the main causes differ in their timing and in what comes with them. No single feature proves one, and they can overlap, but together they point the way. The table compares five of them.

Swipe the table sideways to compare all five →

Feature	A spinal fluid leak, on its own	After a lumbar puncture or epidural	POTS	Low blood pressure on standing	Too little fluid (dehydration)
What comes with it	Neck pain or stiffness, nausea, and ringing or muffled hearing are common	Neck stiffness or changes in hearing are common	A fast heartbeat, light-headedness, blurred vision or nausea when upright	An ache mostly in the back of the neck, sometimes spreading up to the back of the head (a "coat-hanger" ache); light-headedness	Thirst, a dry mouth, dark urine, and light-headedness when you stand
How soon after you sit up or stand	Within seconds to hours; it may be absent on waking and build through the day	Often within seconds to minutes; it usually starts within 1 to 2 days of the procedure, and nearly always within a week	Soon after standing	Within minutes of standing (3 to 5 minutes in one study), or after a long time sitting	Especially when you stand up
What eases it	Lying flat, sometimes within a minute; later in the illness, more slowly or only partly	Lying flat; it usually settles on its own within a week or two	Sitting or lying down	Lying down, within about 5 to 20 minutes	Drinking fluids and resting
Other clues	No procedure; sometimes after a strain or a bout of coughing; sometimes very flexible joints	A lumbar puncture, epidural or spinal anaesthetic in the last few days	Heart rate rises by 30 beats a minute or more within 10 minutes of standing (40 or more in teenagers), without a fall in blood pressure; most common in women aged 15 to 45	Blood pressure falls by 20 or more (top number) or 10 or more (bottom number) within 3 minutes of standing	A hot day, exercise, vomiting or diarrhoea, or not drinking enough

A spinal fluid leak. Low pressure of the fluid around the brain, after a procedure or on its own: see the next section.
POTS (postural orthostatic tachycardia syndrome). A condition that causes a fast heartbeat and other symptoms when you stand up, from an abnormal response of the nervous system that controls the heart and blood vessels. Headache is common in it: in a US study of 24 people with POTS, about 6 in 10 had a headache that came on when upright, and nearly all also had migraine. POTS affects about 2 to 10 in every 1,000 people, mostly women aged 15 to 45. Because it can cause the same pattern as a leak, the classification of headache disorders advises ruling POTS out before a blood patch is given for a suspected leak, and the UK guideline on spinal fluid leaks lists it among the conditions to consider. It is diagnosed with a stand test (see below). Read more about POTS testing in Sydney.
Low blood pressure on standing (orthostatic hypotension). Blood pressure drops when you stand up after sitting or lying down. The ache is mostly in the back of the neck and shoulders, sometimes spreading up to the back of the head, and comes only when you are upright: in the classification, 75 in 100 people with low blood pressure on standing reported neck pain when they were asked. Light-headedness, blurred or dimmed vision and feeling faint often come with it. Your doctor will check your blood pressure lying down and standing, and whether any of your medicines could be lowering it.
Too little fluid (dehydration). After a hot day, exercise, vomiting or diarrhoea, or simply not drinking enough, you can feel light-headed, especially when you stand up, and have a headache. It settles with fluids and rest. See headache with nausea for when vomiting and dehydration need a doctor.
Migraine. Migraine pain is made worse by routine activity, so many people lie down during an attack. But migraine comes in attacks lasting 4 to 72 hours, usually with nausea or a dislike of light and noise, and does not reliably ease within minutes of lying flat. A spinal fluid leak is often mistaken for migraine at first. Read our migraine overview.
Neck problems (cervicogenic headache). A headache that starts in the neck and changes with neck movement or position, rather than with standing itself. The UK guideline lists it among the conditions to tell apart from a leak. See cervicogenic headache.
Cough and strain headaches. A headache set off by coughing, sneezing or straining, lasting seconds to minutes, is a different pattern from a standing headache; it is checked by a doctor (see the list at the top), and a headache brought on by exercise is covered in headache after exercise.
The opposite pattern: worse lying down. A headache that is worse when you lie down, or worst on waking with vomiting or blurred vision, can mean raised pressure inside the head, and needs your GP the same day (see the list at the top).

Where most people sit

The table is a guide, not a diagnosis. Several of these can happen together: in the US study of people with POTS, nearly all also had migraine, and in rare cases a spinal fluid leak brings on a fast heartbeat on standing too. Sorting out which is which is the main job of a consultation, and each has its own treatment.

Spinal Fluid Leaks: After a Procedure, or Out of the Blue

A leak can follow a needle in the back, or happen with no procedure at all. The two behave a little differently.

After a lumbar puncture, an epidural or a spinal anaesthetic (post-dural puncture headache). A lumbar puncture (a spinal tap) leaves a tiny hole in the lining of the spine, and the needle used for an epidural occasionally goes through the lining by accident. Fluid can leak through the hole for a few days. The headache usually starts within a day or two, and nearly always within a week, and is worse sitting or standing, often within seconds to minutes of getting up; neck stiffness and changes in hearing are common with it. In trials, it followed about 11 in 100 lumbar punctures with standard needles and about 4 in 100 with finer, rounded-tip (atraumatic) needles. In a Brisbane audit of nearly 13,000 labour epidurals, an accidental puncture was recognised in about 1 in 100, and two-thirds of those women developed the headache. Lying flat after a lumbar puncture has not been shown to prevent it, in a Cochrane review of 24 trials. It usually settles on its own: the classification says within 2 weeks, and in a Norwegian study the middle (median) duration was 6 days. If it is severe or stops you doing everyday things, a blood patch is the usual treatment (see below).
A leak that happens on its own (spontaneous intracranial hypotension). Sometimes fluid leaks from the spine without any procedure. It is uncommon: two US population studies found about 4 new cases a year for every 100,000 people. In a US series of 568 people, two-thirds were women and the average age was 46. The leak can come from a small tear in the lining, often caused by a tiny bony spur; from a weak pouch in the lining around a nerve root; or from a direct connection between the fluid and a vein (a CSF-venous fistula). In about half of people, no leak is found on scans. Some people remember a strain or a bout of coughing before it began. Some have a connective-tissue condition or very flexible joints, but most do not: in one controlled study, very flexible joints were no more common in people with a leak than in people without one.
How a leak headache feels. It is usually worse upright and better lying down: 92 in 100 had this pattern in a pooled analysis of 144 studies, about half felt sick, and about 4 in 10 had neck pain or stiffness. Ringing in the ears, a muffled or blocked feeling in the ears, and dizziness are common too. The classification describes two patterns: a headache that comes within seconds of standing and goes within a minute of lying down, like the headache after a lumbar puncture, or one that builds over minutes or hours upright and only partly eases after minutes or hours lying down. Some people wake without a headache and only develop it later in the day, and the pattern can become much less obvious over time, which is why the way it started matters. It can also start suddenly and severely, and many people first go to an emergency department.
Why it is missed. In the US series of 18 people, 17 were first given another diagnosis, and in a UK survey, people saw their GP an average of three times before being referred to a specialist. A brain MRI scan shows signs of low pressure in most people with a leak, but it is normal in about 1 in 5, and a lumbar puncture often shows a normal pressure: in a US series of 106 people, only about a third had a low reading. A normal scan or a normal pressure does not rule a leak out.
What a leak can lead to. Most people with a leak never have a serious complication, but a few do, which is the reason to find and treat a leak rather than leave it. The most common is a collection of blood over the surface of the brain (a subdural haematoma), found in about 13 to 20 in 100 people in published series, and more often in men. A clot in a vein of the brain happens in about 1 to 2 in 100. Rarely, after a leak has been left open for years, iron can stain the surface of the brain, and a very small number of people develop changes in behaviour and sleepiness from brain sagging, which usually improve once the leak is treated. After a lumbar puncture or epidural, these problems are rarer still. A headache that is now just as bad lying down as upright, or becomes constant or much more severe, over hours or days needs an emergency department the same day, and one with drowsiness, confusion, a seizure, or weakness or numbness needs 000 (see the lists at the top).

Where most people sit

Most headaches after a lumbar puncture or epidural settle within a week or two, or with a blood patch. Leaks that happen on their own are uncommon and easily missed, but once they are recognised they can be treated, and most people improve with treatment, sometimes after more than one procedure.

The Blood Patch: What It Is, Who Does It and What to Expect

An epidural blood patch is the usual first procedure for a spinal fluid leak, whether the leak followed a puncture or happened on its own. It uses your own blood. A small amount, usually about 20 mL (four teaspoons), is taken from a vein in your arm and injected straight away into the epidural space, the narrow space just outside the lining of the spine, usually in the lower back. The blood spreads around the lining and clots; it is thought to seal the hole and to restore the pressure around the brain, although exactly how it works is not fully known. A patch in the lower back, away from the leak, is called non-targeted; a patch placed at the level of a leak found on a scan is called targeted.

A CT-guided blood patch uses a CT scanner to show exactly where the needle is, so the blood can be placed precisely. It is usually done by a radiologist, a doctor who specialises in scans and scan-guided procedures, often a neuroradiologist, whose work is the brain and spine, in a hospital or radiology practice; some pain specialists also do scan-guided patches. A blood patch for a headache after an epidural in childbirth is usually done by an anaesthetist at the maternity hospital, often without scan guidance. Dr Granot does not perform blood patches: when one is needed, you are referred to an experienced neuroradiologist who performs them under CT guidance.

Before. Tell the clinic when you book if you take blood-thinning medicine, because it may need to be paused, and do not change it without advice from both the clinic and your own doctor; a blood test to check your clotting may be needed on the day. Follow the clinic's instructions about eating beforehand, and arrange for someone to drive you home.
On the day, and does it hurt? You lie on your front on the CT table, the skin of your lower back is numbed, and the needle is guided into place using the scans. Blood is then taken from your arm and injected slowly. It is normal to feel pressure or an ache in the back, sometimes spreading to the buttocks or legs, as the blood goes in; tell the doctor if it becomes painful, because the injection is slowed or stopped when it becomes too uncomfortable. The procedure takes about 30 minutes.
Afterwards. You lie flat for a while, usually about 2 hours after a patch for a headache after a puncture, and sometimes longer, up to a day, after a patch for a leak that happened on its own; many people go home the same day. For a leak that happened on its own, the UK guideline advises lying flat as much as possible for 1 to 3 days, and avoiding bending, lifting, straining, twisting and strenuous exercise for 4 to 6 weeks. After a headache from an epidural, Australian maternity hospitals advise avoiding straining and lifting anything heavier than your baby for 2 to 6 weeks. Only one small trial has compared how long to lie flat, and we found no trial of limits on activity, so follow the instructions of the team that did your patch. Backache or stiffness for a few days is common.
How well it works. After a puncture, Australian and UK hospital leaflets say the headache goes within 24 hours for about 6 to 7 in 10 people, and a second patch helps many of the rest; most people do not need more than two. In a Perth audit of 100 women after an accidental puncture in labour, 58 had a blood patch: the first patch gave complete relief to about 2 in 3 of them and at least partial relief to 95 in 100, but severe headache came back in about 3 in 10, and about 3 in 10 had more than one patch. After a leak that happened on its own, one patch settled the headache in about 6 in 10 (64 in 100) in the pooled analysis of 144 studies; some people need two or more, and patches placed at the leak did better in some studies. When patches do not hold, a procedure to seal the leak, or an operation, is considered at a centre that treats leaks often. A good response also helps confirm the diagnosis: in a study of 86 people who had a first blood patch at St George Hospital in Sydney, how the headache responded within 72 hours was a highly accurate guide to a leak in that hospital's patients, while brain and spine MRI and symptom scores missed too many to be of practical use on their own.
Risks. Serious problems are rare. Backache and stiffness are common and usually settle within a few days, though they can last a few weeks, and there may be bruising. There is a small chance, under 1 in 100, that the needle makes another hole in the lining, which can make the headache worse. Nerve damage, infection and bleeding into the back are very rare: one NHS leaflet puts serious nerve injury at less than 1 in 10,000. After a successful patch for a leak that happened on its own, about 1 in 4 people get a different headache for a while, worse when lying down, because the pressure around the brain bounces back higher than usual (rebound high pressure); it usually settles, but contact the team the same day, because it is treated differently from a returning leak. A blood patch does not stop you having an epidural or spinal anaesthetic in the future.
When to get help after a patch. Go to an emergency department straight away for new numbness or weakness in your legs, numbness around your bottom or genitals, trouble passing urine or controlling your bladder or bowel, or severe or increasing back pain, or new severe pain in a leg. For a fever, or redness, swelling or pus where the needle went in, contact the team that did the patch straight away, or go to an emergency department now. Contact the team the same day for new nausea or vomiting, or a new headache that is worse when you lie down and better when you are upright; go to an emergency department the same day if the headache is now just as bad lying down as upright, or becomes constant or much more severe, over hours or days, or if a headache that is worse lying down is severe or keeps getting worse; call 000 if it comes with drowsiness, confusion, a seizure, or weakness or numbness of the face, an arm or a leg (see the lists at the top).

Where most people sit

A blood patch is a common, well-established procedure, and serious complications are rare. It does not always work the first time, but most people improve with treatment, sometimes after more than one patch.

How Is the Cause of a Headache When Standing Up Found?

Mostly from your story and an examination, then the test that answers the question the story raises.

Your story. When it started, and whether a lumbar puncture, an epidural, a spinal anaesthetic, a strain or a bout of coughing came before it; how soon after getting up it comes, and how quickly lying flat eases it; whether the pattern has changed; what comes with it, such as neck pain, nausea, ringing or muffled hearing, light-headedness, a racing heart or fainting; very flexible joints; how much you drink; recent illness; and any new medicine.
The examination. Your blood pressure and heart rate lying down and standing, and a full neurological examination, including the back of the eyes.
A stand test, when POTS or low blood pressure on standing is possible. Your heart rate and blood pressure are measured after 5 minutes lying down, then every minute for 10 minutes standing. One normal test does not rule POTS out, because the symptoms come and go. Autonomic testing, which includes a stand test, is available at Autonomics Australia in Bondi Junction: it takes 40 to 60 minutes, no referral is needed, and there is no Medicare rebate for the test.
An MRI scan of the brain, when a leak is possible. It is needed to confirm the diagnosis: it shows signs of low pressure in most people with a leak, such as a thickened lining of the brain or a brain that sits lower than usual, and doctors can score these signs to judge how likely a spinal leak is. It is normal in about 1 in 5 people with a leak, so a normal scan does not rule one out.
Scans of the spine, to find the leak. An MRI of the whole spine is needed to look for where the fluid is leaking. When finding the exact site would change the treatment, specialised scans that show where fluid is escaping (myelography, sometimes done lying on your side) are arranged at centres that do them often. Even so, the leak is not always found.
A lumbar puncture to measure the pressure is often not needed. The classification says it is not necessary when the MRI shows signs of a leak, and the pressure is normal in many people with a proven leak.
The response to a blood patch. A clear improvement within 3 days of a first patch supports the diagnosis (the Sydney study above).

What Helps a Headache When Standing Up

The treatment depends on the cause, which is why the diagnosis comes first.

After a lumbar puncture, an epidural or a spinal anaesthetic. Most of these headaches settle within a week or two. Lie down when you need to, drink fluids, and take simple pain relief at the dose on the pack; ask your pharmacist which kind suits you, especially if you are breastfeeding. Tell the team that did the procedure: if the headache is severe, or stops you doing everyday things or caring for your baby, a blood patch is usually offered, often a day or two after the headache starts. If you had a baby in the last 6 weeks and the headache is severe, go to your maternity unit or an emergency department now.
A leak that happened on its own. The UK guideline advises up to 2 weeks of simple measures from when the symptoms start, such as lying flat when the headache builds and avoiding straining and heavy lifting, then a blood patch in the lower back if it has not settled; a second patch can follow 2 to 4 weeks later. If patches do not hold, scans to find the leak are done, and a patch placed at the leak, a procedure to close a leaking vein, or an operation is considered at a centre that treats leaks often. In a Swiss study, people treated within about 12 weeks of their symptoms starting did better after surgery.
Some medications may be of benefit in a low-pressure headache. Your doctor can advise whether one suits you.
POTS and low blood pressure on standing. If you feel light-headed, sit or lie down until it passes, and get up slowly. Treatment starts with measures that help the circulation when you are upright, and your doctor can advise which suit you; read about what happens after a POTS diagnosis. Your doctor can also check whether any of your medicines could be lowering your blood pressure.
Fluids. Drink enough, especially in hot weather and after exercise, vomiting or diarrhoea.
If headaches go on for weeks or months, keep pain relief to two or three days a week at most, and to fewer than 10 days a month for some kinds. Daily pain relief at the dose on the pack for a short-lived headache, such as one after a lumbar puncture, does not count against this; taking it on too many days over months (15 or more days a month for simple pain relievers, 10 or more for some others) can itself keep headaches going. Ask your pharmacist which yours is, and see medication overuse headache.

When to See a Neurologist About a Headache When Standing Up

A headache that keeps coming on when you are upright and easing when you lie down (see your GP first, the same day)
A headache after a lumbar puncture or epidural that has not settled within 2 weeks, or after a blood patch
A suspected spinal fluid leak, or a diagnosis of one that needs a plan
Light-headedness, a racing heart or near-fainting when you stand, with headaches
Headaches that change with posture, and very flexible joints or a connective-tissue condition
You have been told your scans are normal, but the pattern goes on
You want a clear diagnosis and a plan

The UK guideline on spinal fluid leaks advises that people with a suspected leak see a neurologist. A consultation involves a detailed history, a neurological examination and a plan: working out which cause fits, arranging scans and, when needed, autonomic testing, and coordinating with your GP. When a blood patch is needed, you are referred to an experienced neuroradiologist who performs it under CT guidance. Dr Ron Granot trained at Prince of Wales Hospital, Sydney, and sees patients in Bondi Junction. For the wider picture, read our migraine overview.

Frequently Asked Questions

Why do I get a headache when I stand up? +

Often because of a dip in blood pressure or a fast heartbeat when you stand (as in POTS), too little fluid, or low pressure of the fluid around the brain. Low pressure most often follows a lumbar puncture, an epidural or a spinal anaesthetic, when fluid leaks through the needle hole for a few days; less often, fluid leaks from the spine on its own (spontaneous intracranial hypotension). A leak headache typically builds within seconds to hours of sitting up or standing and eases when you lie flat, often with neck pain, nausea, or ringing or muffled hearing. Call 000 for a headache that comes on suddenly and severely, reaching its worst within a minute, including one brought on by changing position with fainting, collapse or unusual drowsiness, even if a similar attack has passed before; or a headache with fever and a stiff neck, confusion, weakness, numbness or drooping of the face, an arm or a leg, trouble speaking, a loss of vision or a seizure. If a doctor has diagnosed a headache from a lumbar puncture, an epidural or a spinal fluid leak, your usual headache on sitting up that eases when you lie down does not need 000 on its own. See your GP the same day about a new headache that keeps coming on when you are upright and easing when you lie down, and contact the team that did your procedure the same day about a headache after a lumbar puncture, an epidural or a spinal anaesthetic. If you had a baby in the last 6 weeks, a severe headache, or a headache with vomiting, needs your maternity unit or an emergency department now, even if it eases when you lie down. After any of these procedures, new numbness or weakness in your legs, numbness around your bottom or genitals, trouble passing urine or controlling your bladder or bowel, or severe or increasing back pain, or new severe pain in a leg needs an emergency department now; a fever, or redness, swelling or pus where the needle went in, needs the team that did it, or an emergency department, straight away; and a headache that is now just as bad lying down as upright, or becomes constant or much more severe, over hours or days, needs an emergency department the same day.

When should I worry about a headache when standing up? +

Call 000 or go to an emergency department if it comes on suddenly and severely, reaching its worst within a minute, even if it then eases, including a sudden, severe headache brought on by changing position with fainting, collapse or unusual drowsiness, even if a similar attack has passed before; if it comes with fever and a stiff neck, a rash that does not fade when pressed, confusion, weakness, numbness or drooping of the face, an arm or a leg, trouble speaking, sudden severe dizziness or unsteadiness, a loss of vision, double vision, a new drooping eyelid or one pupil larger than the other, or a seizure; if you have a very high blood pressure reading with the headache (see the list at the top; in pregnancy and after a spinal cord injury, lower readings count); if it started after a head injury and is getting worse, comes with vomiting, drowsiness or confusion, or you take blood-thinning medicine, or clear fluid or blood comes from your nose or an ear after a head injury; or if, after a lumbar puncture, an epidural or spinal anaesthetic, or a blood patch, you have new numbness or weakness in your legs, numbness around your bottom or genitals, trouble passing urine or controlling your bladder or bowel, or severe or increasing back pain, or new severe pain in a leg. If a doctor has diagnosed a headache from a lumbar puncture, an epidural or a spinal fluid leak, your usual headache on sitting up that eases when you lie down does not need 000 on its own. If you have a fever, or redness, swelling or pus where the needle went in, after one of these procedures, contact the team that did it straight away, or go to an emergency department now. Go to an emergency department the same day if a headache after one of these procedures, or with a known leak, is now just as bad lying down as upright, or becomes constant or much more severe, over hours or days. See your GP the same day about a new headache that keeps coming on when you are upright and easing when you lie down, a headache that is getting steadily worse, one that is worse when you lie down, a new headache after 50, or clear fluid that keeps dripping from your nose or an ear. Contact the team that did your procedure the same day about a headache after a lumbar puncture, an epidural or a spinal anaesthetic, or, after a blood patch, new nausea or vomiting, or a new headache that is worse when you lie down and better when you are upright. If you are more than 20 weeks pregnant or had a baby in the last 6 weeks, a severe headache, or a headache with vomiting, needs your maternity unit or an emergency department now, even if it eases when you lie down. Other warning signs are in the lists at the top of this page.

What is a blood patch? +

A blood patch (an epidural blood patch) is the usual first procedure for a headache from a spinal fluid leak. About 20 mL of your own blood is taken from a vein in your arm and injected into the epidural space, the narrow space just outside the lining of the spine, usually in the lower back. The blood spreads around the lining and clots, which is thought to seal the hole and restore the pressure around the brain. In a CT-guided blood patch, a CT scanner shows exactly where the needle is; it is usually done by a radiologist, often a neuroradiologist, in a hospital or radiology practice, and sometimes by a pain specialist. A blood patch after an epidural in childbirth is usually done by an anaesthetist at the maternity hospital. After a lumbar puncture or epidural, the headache goes within 24 hours for about 6 to 7 in 10 people; after a leak that happened on its own, one patch settled the headache in about 6 in 10 in a pooled analysis, and some people need more than one. Go to an emergency department straight away if, after a patch, you have new numbness or weakness in your legs, numbness around your bottom or genitals, trouble passing urine or controlling your bladder or bowel, or severe or increasing back pain, or new severe pain in a leg; for a fever, or redness, swelling or pus where the needle went in, contact the team that did it straight away, or go to an emergency department now; contact the team the same day for new nausea or vomiting, or a new headache that is worse when you lie down and better when you are upright (if it is severe or keeps getting worse, go to an emergency department the same day). Go to an emergency department the same day if the headache is now just as bad lying down as upright, or becomes constant or much more severe, over hours or days; call 000 if it comes with drowsiness, confusion, a seizure, or weakness or numbness of the face, an arm or a leg.

Is a blood patch painful? +

It feels similar to having an epidural, and the skin is numbed first. As the blood goes in, it is normal to feel pressure or an ache in the back, sometimes spreading to the buttocks or legs; tell the doctor, because the injection is slowed or stopped when it becomes too uncomfortable. The procedure takes about 30 minutes. Afterwards, backache or stiffness is common and usually settles within a few days, though it can last a few weeks. Go to an emergency department straight away for severe or increasing back pain, or new severe pain in a leg, new numbness or weakness in your legs, numbness around your bottom or genitals, or trouble passing urine or controlling your bladder or bowel; for a fever, or redness, swelling or pus where the needle went in, contact the team that did it straight away, or go to an emergency department now. Contact the team the same day for new nausea or vomiting, or a new headache that is worse when you lie down and better when you are upright (if it is severe or keeps getting worse, go to an emergency department the same day). Go to an emergency department the same day if the headache is now just as bad lying down as upright, or becomes constant or much more severe, over hours or days; call 000 if it comes with drowsiness, confusion, a seizure, or weakness or numbness of the face, an arm or a leg.

How long does it take to recover from a blood patch? +

For about 6 to 7 in 10 people whose headache followed a lumbar puncture or epidural, the headache goes within 24 hours. You lie flat for a while afterwards, usually about 2 hours, and sometimes longer, up to a day, after a patch for a leak that happened on its own; many people go home the same day, with someone else driving. Backache for a few days is common. Avoid straining, bending and heavy lifting for as long as your team advises: Australian maternity hospitals say 2 to 6 weeks after a headache from an epidural, and the UK guideline says 4 to 6 weeks after a leak that happened on its own, with lying flat as much as possible for the first 1 to 3 days. Only one small trial has compared how long to lie flat, and we found no trial of limits on activity, so follow your team's instructions. Go to an emergency department straight away for new numbness or weakness in your legs, numbness around your bottom or genitals, trouble passing urine or controlling your bladder or bowel, or severe or increasing back pain, or new severe pain in a leg; for a fever, or redness, swelling or pus where the needle went in, contact the team that did it straight away, or go to an emergency department now; contact the team the same day for new nausea or vomiting, or a new headache that is worse when you lie down and better when you are upright (if it is severe or keeps getting worse, go to an emergency department the same day). Go to an emergency department the same day if the headache is now just as bad lying down as upright, or becomes constant or much more severe, over hours or days; call 000 if it comes with drowsiness, confusion, a seizure, or weakness or numbness of the face, an arm or a leg.

What are the risks of a blood patch? +

Serious problems are rare. Backache and stiffness are common and usually settle within a few days, though they can last a few weeks, and there may be bruising. There is a small chance, under 1 in 100, that the needle makes another hole in the lining, which can make the headache worse. Nerve damage, infection and bleeding into the back are very rare. After a successful patch for a leak that happened on its own, about 1 in 4 people get a different headache for a while, worse when lying down, because the pressure bounces back higher than usual; it usually settles, but contact your team the same day. A patch does not stop you having an epidural or spinal anaesthetic in the future. Go to an emergency department straight away for new numbness or weakness in your legs, numbness around your bottom or genitals, trouble passing urine or controlling your bladder or bowel, or severe or increasing back pain, or new severe pain in a leg; for a fever, or redness, swelling or pus where the needle went in, contact the team that did it straight away, or go to an emergency department now; contact the team the same day for new nausea or vomiting, or a new headache that is worse when you lie down and better when you are upright (if it is severe or keeps getting worse, go to an emergency department the same day). Go to an emergency department the same day if the headache is now just as bad lying down as upright, or becomes constant or much more severe, over hours or days; call 000 if it comes with drowsiness, confusion, a seizure, or weakness or numbness of the face, an arm or a leg.

How long does a headache after a lumbar puncture or epidural last? +

It usually starts within a day or two of the procedure, and nearly always within a week, and most settle within a week or two: in a Norwegian study the median was 6 days, and the classification of headache disorders says it goes within 2 weeks on its own, or after a blood patch. If it is severe or stops you doing everyday things or caring for your baby, contact the team that did the procedure: a blood patch is usually offered, and the headache goes within 24 hours for about 6 to 7 in 10 people. Go to an emergency department the same day if the headache is now just as bad lying down as upright, or becomes constant or much more severe, because rarely it can mean a collection of blood over the brain or a clot in a vein of the brain; call 000 if it comes with drowsiness, confusion, a seizure, or weakness or numbness of the face, an arm or a leg. If you had a baby in the last 6 weeks, a severe headache, or a headache with vomiting, needs your maternity unit or an emergency department now. After the procedure, new numbness or weakness in your legs, numbness around your bottom or genitals, trouble passing urine or controlling your bladder or bowel, or severe or increasing back pain, or new severe pain in a leg needs an emergency department now, and a fever, or redness, swelling or pus where the needle went in, needs the team that did it, or an emergency department, straight away.

What is spontaneous intracranial hypotension, and is a CSF leak serious? +

Spontaneous intracranial hypotension means low pressure of the fluid around the brain from a leak in the spine that happens without a procedure. It is uncommon, about 4 new cases a year in every 100,000 people, and easily missed, often mistaken for migraine at first. The usual sign is a headache that builds when you are upright and eases when you lie flat. Most people never have a serious complication, but some do: a collection of blood over the brain (a subdural haematoma) was found in about 13 to 20 in 100 people in published series, and a clot in a vein of the brain in about 1 to 2 in 100. That is why a leak is looked for and treated rather than left. Most people improve with treatment, sometimes after more than one blood patch or procedure, though a minority have symptoms that linger. Call 000 for a headache that comes on suddenly and severely, reaching its worst within a minute, or a headache with drowsiness, confusion, a seizure, or weakness or numbness of the face, an arm or a leg. Go to an emergency department the same day if a known leak headache is now just as bad lying down as upright, or becomes constant or much more severe, over hours or days, and see your GP the same day about a new headache that keeps coming on when you are upright and easing when you lie down. If, with a known leak, lying down has slowly helped less and less over weeks or months, see your GP or the doctor treating your leak the same day.

Can POTS cause a headache when standing up? +

Yes. POTS (postural orthostatic tachycardia syndrome) causes a fast heartbeat and other symptoms when you stand, and headache is one of them: in a US study of 24 people with POTS, about 6 in 10 had a headache that came on when upright, and nearly all also had migraine. It is diagnosed with a stand test: the heart rate rises by 30 beats a minute or more within 10 minutes of standing (40 or more in teenagers), without a fall in blood pressure. Because POTS and a spinal fluid leak can cause the same pattern, the classification of headache disorders advises ruling POTS out before a blood patch is given for a suspected leak. If a doctor has diagnosed POTS, your usual light-headedness or dizziness when you stand, which eases when you sit or lie down, does not need 000 on its own. Call 000 for a headache that comes on suddenly and severely and reaches its worst within a minute, including one brought on by changing position with fainting, collapse or unusual drowsiness, even if a similar attack has passed before; for dizziness that is sudden and severe, does not ease when you lie down, or comes with double vision, slurred speech, trouble walking, or numbness or weakness; or if you feel very unwell, or have a faint that is not like your usual ones or from which you do not recover quickly and fully.

Important: This page is general health information for adults living in Australia and is not a substitute for individual medical advice. If you have a sudden, severe headache that reaches its worst within a minute, a sudden, severe headache on changing position with fainting, collapse or drowsiness, a very high blood pressure reading (a top number of 180 or more, or a bottom number of 120 or more; lower readings count in pregnancy and after a spinal cord injury) with a headache, a headache with a stiff neck and fever, confusion, a headache with weakness, numbness or drooping of the face, an arm or a leg, sudden loss of vision, double vision, slurred speech or sudden unsteadiness, a painful red eye with blurred vision, a headache that is getting worse or comes with vomiting after a head injury, clear fluid or blood from the nose or an ear after a head injury, new numbness or weakness in the legs, numbness around the bottom or genitals, trouble passing urine or controlling the bladder or bowel, severe or increasing back pain or new severe pain in a leg, or a fever or redness, swelling or pus where the needle went in, after a lumbar puncture, an epidural or spinal anaesthetic, or a blood patch, a seizure, or, if you are over 50, a new headache with blurring, double vision or dimming of sight, or any other warning sign listed at the top of this page, call 000 or go to an emergency department. If you are more than 20 weeks pregnant or had a baby in the last 6 weeks and have a severe headache, vomiting with a headache, blurred vision or flashing lights, go to your maternity unit or an emergency department now. Diagnosis and treatment decisions are made on an individual basis with your treating doctor.

Sources: the studies and guidelines behind this page

The international classification of headache disorders (sections 1.1, 4.1, 4.4, 6.2.2, 7.1.1, 7.2, 7.2.1, 7.2.2, 7.2.3, 7.4.1, 7.4.1.1, 7.7, 9.1.1 and 10.3.4, and appendix A10.7): Headache Classification Committee of the International Headache Society. Cephalalgia 2018;38:1-211. PubMed 29368949
How common leaks are, who gets them, and how often they are missed: Schievink WI, et al. Cephalalgia 2022;42:312-316 (PubMed 34553617); Pradeep A, et al. Interv Neuroradiol 2025;31:364-368 (PubMed 36945844); Schievink WI, et al. Neurology 2016;87:673-9 (the series of 568 people; PubMed 27440149); Schievink WI. Arch Neurol 2003;60:1713-8 (the series of 18 people; PubMed 14676045); Cheema S, et al. BMJ Open 2022;12:e057438 (the UK survey; PubMed 35058269).
Symptoms, scans and pressure: D'Antona L, et al. JAMA Neurol 2021;78:329-337 (the pooled analysis of 144 studies; PubMed 33393980); Kranz PG, et al. Cephalalgia 2016;36:1209-1217 (the series of 106 people; PubMed 26682575); Urbach H, et al. Dtsch Arztebl Int 2020;117:480-487 (PubMed 33050997); Nasiri D, et al. AJNR Am J Neuroradiol 2025;46:1486-1492 (bony spurs; PubMed 39788630); Leep Hunderfund AN, Mokri B. J Neurol 2012;259:306-10 (headache later in the day; PubMed 21811806).
Flexible joints and connective tissue: Reinstein E, et al. Eur J Hum Genet 2013;21:386-90 (PubMed 22929030); Liu FC, et al. Cephalalgia 2011;31:691-5 (the controlled study; PubMed 21220378).
Complications: Kim YJ, et al. Headache 2017;57:1593-1600 (PubMed 28653430); Schievink WI, et al. J Neurosurg 2005;103:608-13 (PubMed 16266041); Lin PT, et al. Headache 2024;64:1298-1308 (PubMed 39221780); Schievink WI, Maya MM. Headache 2008;48:1511-9 (PubMed 19076649); Ferrante E, et al. J Neurol Sci 2021;425:117467 (PubMed 33894614); Schievink WI, et al. Neurology 2021;97:e1964-e1970 (PubMed 34504024); Lashkarivand A, Eide PK. Neurology 2022;98:798-805 (PubMed 35338080).
The blood patch: Cheema S, et al. J Neurol Neurosurg Psychiatry 2023;94:835-843 (the UK guideline on spontaneous intracranial hypotension; PubMed 37147116); Uppal V, et al. JAMA Netw Open 2023;6:e2325387 (the international guideline on headache after a dural puncture); Cho KI, et al. Neurology 2011;76:1139-44 (PubMed 21444899); Davies MJ, et al. World Neurosurg 2020;137:e242-e250 (the Sydney study of 86 people; PubMed 32004736); Schievink WI, et al. Neurol Clin Pract 2019;9:93-100 (rebound high pressure; PubMed 31041122); Banks S, et al. Int J Obstet Anesth 2001;10:172-6 (the Perth audit; PubMed 15321606); Safa-Tisseront V, et al. Anesthesiology 2001;95:334-9 (PubMed 11506102); Gupta A, et al. Br J Anaesth 2022;129:758-766 (PubMed 36064491); Abouleish E, et al. Anesth Analg 1975;54:459-63 (PubMed 125053); Martin R, et al. Can J Anaesth 1994;41:23-5 (PubMed 8111939); Shaparin N, et al. Pain Physician 2014;17:119-25 (PubMed 24658472); Häni L, et al. J Neurol 2022;269:1439-1446 (the Swiss surgical study; PubMed 34274993).
Headache after a lumbar puncture or epidural: Nath S, et al. Lancet 2018;391:1197-1204 (PubMed 29223694); Arevalo-Rodriguez I, et al. Cochrane Database Syst Rev 2016;3:CD009199 (PubMed 26950232); Vilming ST, Kloster R. Cephalalgia 1997;17:778-84 (the Norwegian study; PubMed 9399009); Eley VA, et al. J Anesth 2022;36:399-404 (the Brisbane audit; PubMed 35474399); Moore AR, et al. JAMA Neurol 2020;77:65-72 (PubMed 31524925); Cuypers V, et al. Int J Obstet Anesth 2016;25:58-65 (PubMed 26597409); Chambers DJ, et al. Int J Obstet Anesth 2022;49:103218 (PubMed 34598860).
POTS and low blood pressure on standing: Khurana RK, Eisenberg L. Cephalalgia 2011;31:409-15 (the US study of 24 people with POTS; PubMed 20819844); Fedorowski A. J Intern Med 2019;285:352-366 (PubMed 30372565); Sivakoti K, et al. Am J Med 2026 (PubMed 42665152); Mokri B, Low PA. Neurology 2003;61:980-2 (PubMed 14557573); Khurana RK. Cephalalgia 2012;32:731-7 (PubMed 22711896); Kim MJ, Farrell J. Am Fam Physician 2022;105:39-49 (PubMed 35029940).
Guidance: healthdirect, Headaches, Lumbar puncture, Epidural anaesthetic, Postural orthostatic tachycardia syndrome (POTS), Low blood pressure, Lightheadedness, Dehydration and Head injuries; InsideRadiology (Royal Australian and New Zealand College of Radiologists), Myelogram and Image guided lumbar epidural injection; The Royal Women's Hospital, Melbourne, Headache after an epidural or spinal anaesthetic; Royal Hospital for Women, Randwick, Discharge instructions after epidural blood patch; Mercy Hospitals Victoria and King Edward Memorial Hospital, Perth, leaflets on headache after an epidural; SA Health, Post dural puncture headache perinatal practice guideline; Brain Foundation, Spinal cerebrospinal fluid (CSF) leak; Migraine and Headache Australia, High and low pressure headache; Australian POTS Foundation, Diagnosing POTS; AusDoc, When to suspect a cerebrospinal fluid leak; Royal College of Anaesthetists and Obstetric Anaesthetists' Association, Headache after a spinal or epidural; Royal United Hospitals Bath NHS, Epidural blood patch; CSF Leak Association; Spinal CSF Leak Foundation.

Headaches That Come On When You Stand?

Book a consultation with Dr Ron Granot — neurologist with a special interest in headache, Bondi Junction. Ask your GP for a referral, then get in touch.

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Last reviewed: 19 October 2026 by Dr Ron Granot, FRACP — Consultant Neurologist, East Neurology, Bondi Junction.