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The article describes three scenarios in the diagnosis of spinal cerebrospinal fluid (CSF) leaks that require advanced clinical reasoning. These include suspected CSF leak but misdiagnosed and seems to be otherwise consistent with spontaneous hypotension and post-dural puncture headache, the presence of CSF leak but with change symptoms such as cerebral venous thrombosis, and treated CSF leak but with retention of symptoms or recurrence.

Spontaneous intracranial hypotension (SIH) is associated with cerebrospinal fluid (CSF) hypovolemia, often from a traumatic dural tear from a calcified spinal osteophyte. Visualizing osteophytes on CT imaging can guide decision making on candidate leak sites. We report the atypical case of a 41-year-old woman whose ventral CSF leak was associated with an osteophyte that resorbed over an 18-month period. Full workup and treatment were delayed due to unexpected pregnancy and completion of gestational cycle with delivery of a healthy term infant. The patient initially presented with persistent orthostatic headaches with nausea and blurred vision. Initial MRI suggested brain sagging among other findings consistent with SIH. CT myelogram showed an extensive thoracic CSF leak with a prominent ventral T11–T12 osteophyte and multiple small disc herniations. The patient did not respond to epidural blood patches and deferred additional imaging due to her pregnancy. CT myelography performed 5 months post-partum showed an absence of the osteophyte; a follow-up digital subtraction myelogram performed 10 months post-partum showed evidence of source leak at T11–T12 level. T11–T12 laminectomy visualized and repaired a 5 mm ventral dural defect with symptom resolution. This report highlights the potential for a resorbed osteophyte to be the causative agent for long-standing dural tears that do not show visible calcifications on myelography. [ABSTRACT FROM AUTHOR]

Objective: To provide a position statement update from The American Headache Society specifically regarding therapies targeting calcitonin gene‐related peptide (CGRP) for the prevention of migraine. Background: All migraine preventive therapies previously considered to be first‐line treatments were developed for other indications and adopted later for migraine. Adherence to these therapies is often poor due to issues with efficacy and tolerability. Multiple new migraine‐specific therapies have been developed based on a broad foundation of pre‐clinical and clinical evidence showing that CGRP plays a key role in the pathogenesis of migraine. These CGRP‐targeting therapies have had a transformational impact on the management of migraine but are still not widely considered to be first‐line approaches. Methods: Evidence regarding migraine preventive therapies including primary and secondary endpoints from randomized placebo‐controlled clinical trials, post hoc analyses and open‐label extensions of these trials, and prospective and retrospective observational studies were collected from a variety of sources including PubMed, Google Scholar, and ClinicalTrials.gov. The results and conclusions based upon these results were reviewed and discussed by the Board of Directors of The American Headache Society to confirm consistency with clinical experience and to achieve consensus. Results: The evidence for the efficacy, tolerability, and safety of CGRP‐targeting migraine preventive therapies (the monoclonal antibodies: erenumab, fremanezumab, galcanezumab, and eptinezumab, and the gepants: rimegepant and atogepant) is substantial, and vastly exceeds that for any other preventive treatment approach. The evidence remains consistent across different individual CGRP‐targeting treatments and is corroborated by extensive "real‐world" clinical experience. The data indicates that the efficacy and tolerability of CGRP‐targeting therapies are equal to or greater than those of previous first‐line therapies and that serious adverse events associated with CGRP‐targeting therapies are rare. Conclusion: The CGRP‐targeting therapies should be considered as a first‐line approach for migraine prevention along with previous first‐line treatments without a requirement for prior failure of other classes of migraine preventive treatment. [ABSTRACT FROM AUTHOR]

The article emphasizes the importance of localization in headache medicine, advocating for a systematic approach to diagnosis that considers where the pain and associated symptoms are located in the nervous system or surrounding structures, with the goal of ensuring that serious secondary headache disorders are not overlooked, ultimately leading to better patient care.