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A 23-year-old man attends the emergency department with a headache that worsens when standing and improves when lying flat. The headache is moderate in severity. He denies any visual changes, photophobia, neck stiffness, or other neurological changes. He has a past medical history of Marfan's syndrome. He takes no regular medication and has not been using analgesia for his headache. On examination, he shows no neurological compromise, including an unremarkable fundoscopy.

What is the most likely diagnosis?

Answer :

The most likely diagnosis is orthostatic headache, commonly associated with increased intracranial pressure conditions like spontaneous intracranial hypotension. Further investigations may be necessary for confirmation, and treatment options usually involve conservative management.

The most likely diagnosis for the 23-year-old man with a headache that worsens when standing and improves when lying flat is orthostatic headache. This type of headache is commonly associated with conditions that cause increased intracranial pressure, such as a condition called spontaneous intracranial hypotension (SIH). SIH is often seen in patients with connective tissue disorders, such as Marfan's syndrome. It is characterized by headaches that are aggravated by an upright position and relieved by lying flat. Other symptoms may include neck pain, nausea, and tinnitus.

To confirm the diagnosis, further investigations such as an MRI or a lumbar puncture may be necessary. Treatment options for orthostatic headaches usually involve conservative management, including rest, avoiding activities that worsen symptoms, and increasing fluid intake. In some cases, a blood patch may be performed to seal any spinal fluid leaks.

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