Key takeaways

  • Precision diagnosis is improving headache care. Advanced imaging techniques now allow accurate localisation of CSF leaks, enabling definitive targeted treatment rather than empirical management.
  • Headache disorders involve multiple biological mechanisms. Studies in IIH demonstrated that neurovascular, inflammatory and immune pathways contribute to headache generation alongside pressure-related mechanisms.
  • Outcome measures need to become more patient-centred. Both migraine and SIH research highlighted the importance of looking beyond traditional endpoints, whether considering long-term complications such as superficial siderosis or recognising that fatigue, cognitive dysfunction and sensory symptoms remain disabling even when headache improves.

1. Targeted treatment for spontaneous intracranial hypotension (SIH)

This presentation reviewed outcomes following targeted treatment of spinal CSF leaks, including surgery and transvenous embolisation, in patients with spontaneous intracranial hypotension.

The speaker showed that while non-targeted epidural blood patches remain useful for symptomatic relief, they rarely result in complete radiological resolution of the leak. Advances in dynamic CT myelography and digital subtraction myelography now allow experienced neuroradiologists to identify the precise site of leakage in many patients, enabling definitive targeted treatment.

Both surgery and embolisation achieved high rates of clinical improvement and radiological resolution, with low complication rates. Surgery is now often performed as a day-case procedure, while embolisation represents a minimally invasive alternative for selected CSF-venous fistulas.

Conclusion: Modern imaging has transformed the management of SIH. Targeted surgery and embolisation provide excellent outcomes when the leak can be identified, while blood patches should increasingly be viewed as a symptomatic treatment rather than definitive therapy. Long-term follow-up remains important because untreated leaks may eventually lead to complications such as superficial siderosis.

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2. CGRP-provoked headache in idiopathic intracranial hypertension

This experimental study investigated whether infusion of calcitonin gene-related peptide (CGRP) could provoke headache in patients with idiopathic intracranial hypertension (IIH) and examined associated vascular and immune responses.

CGRP induced migraine-like headache in the majority of participants, significantly more frequently than placebo. During attacks, investigators observed changes suggesting altered intracranial compliance together with neurovascular changes. Blood analysis demonstrated alterations in several circulating cytokines, indicating activation of inflammatory and neuroimmune pathways during CGRP-induced headache.

Conclusion: Headache in IIH appears to involve mechanisms beyond raised intracranial pressure alone. CGRP-mediated pathways and neuroimmune activation may contribute substantially to symptom generation, supporting further research into CGRP-targeted therapies and inflammatory mechanisms in IIH.

3. CSF biomarkers of superficial siderosis in spontaneous intracranial hypotension

This study explored whether cerebrospinal fluid biomarkers could identify patients with SIH who are developing superficial siderosis, a serious long-term complication of chronic CSF leakage.

Although most CSF abnormalities were mild, including modest elevations of protein and white cell count, approximately 5–10% of patients had elevated bilirubin or ferritin concentrations, indicating chronic blood breakdown products within the CSF. Importantly, several patients demonstrated abnormal CSF biomarkers despite having no MRI evidence of superficial siderosis.

Conclusion: CSF biomarkers may identify patients at risk of superficial siderosis before MRI changes become apparent. Combining MRI findings with CSF ferritin and bilirubin measurements may improve risk stratification, patient counselling and decisions regarding further investigation or definitive treatment.

4. Predictors of response to CGRP monoclonal antibodies in migraine

This real-world service evaluation examined which patient characteristics predict response to CGRP monoclonal antibodies in migraine.

Overall response rates were high, with many patients achieving meaningful reductions in headache burden. Better outcomes were associated with older age at treatment initiation, shorter migraine duration and fewer previously failed preventive therapies. Longer disease duration, a greater burden of associated symptoms and multiple previous preventive treatment failures predicted a poorer response.

Conclusion: Patients appear to derive greater benefit when CGRP monoclonal antibodies are introduced earlier in the course of migraine rather than after years of refractory disease. Earlier intervention may therefore improve long-term outcomes.

5. Orthostatic headache in migraine

This study examined whether orthostatic headache occurs in migraine and how it can be distinguished from spontaneous intracranial hypotension.

The investigators found that many patients with migraine reported worsening on standing and improvement when lying down, potentially mimicking SIH. However, unlike SIH, migraine headaches rarely resolved completely in the supine position. Instead, lying down tended to reduce symptom severity rather than abolish symptoms.

The researchers also identified differences in headache pattern, onset and associated symptoms that may help distinguish migraine from SIH when neuroimaging is normal.

Conclusion: Orthostatic headache is not specific to spontaneous intracranial hypotension. Clinicians should focus on the consistency of postural symptoms and whether headaches return to baseline after lying down, rather than simply asking whether posture affects headache.

6. Effects of CGRP monoclonal antibodies on non-headache migraine symptoms

This presentation explored the impact of CGRP monoclonal antibodies on the non-pain symptoms of migraine.

Patients identified fatigue, cognitive dysfunction (“brain fog”), neck stiffness, photophobia, phonophobia, osmophobia, nausea and movement sensitivity as some of the most disabling aspects of migraine. While many patients experienced improvement in headache frequency, a substantial proportion continued to report persistent non-headache symptoms.

Nausea, vomiting, fatigue and photophobia were among the symptoms most likely to improve following treatment. By contrast, neck stiffness, osmophobia, phonophobia and cognitive symptoms showed a more limited response.

The discussion suggested these persistent symptoms may involve mechanisms beyond CGRP signalling, highlighting the complexity of migraine biology.

Conclusion: Treatment success should not be judged solely by reductions in headache days. Non-pain symptoms remain an important source of disability for many patients despite successful headache control, and should be routinely assessed when evaluating the effectiveness of CGRP-targeted therapies.

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