37-year-old patient, whose only medical history was extrinsic asthma. She had received epidural analgesia 1 month earlier for a euthecological delivery in another hospital. The hospital discharge report noted an accidental dural puncture during the epidural technique and occipital headache during the first 12 h postpartum, which had subsided with medical treatment (caffeine, paracetamol) and rest. However, once at home, the patient again began to experience occipital pain, which she treated daily with analgesics; after 1 month of recurrent pain, she consulted the emergency department of our hospital.
The patient presented with occipital pain that worsened with standing and Valsalva manoeuvres. She was afebrile. Magnetic resonance imaging (MRI) of the brain revealed Chiari malformation type I (caudal displacement of the cerebellar tonsils through the foramen magnum) and diffuse thickening of the meninges. The patient was referred to the anaesthesia department for an epidural blood patch, but refused the technique for fear of a new epidural. Treatment with dexamethasone and analgesics was started and the pain subsided after 4 days.
After 6 months, the patient was reviewed at the neurology outpatient clinic and a new MRI scan was performed, showing the persistence of the anatomical abnormality corresponding to Chiari I syndrome, but noting that the meningeal thickening had disappeared. Clinically, the patient did not report pain at baseline, but she did report pain in relation to Valsalva manoeuvres or coughing; according to her, this symptom was prior to this process.
