In the early morning light of her home in Dover, Ohio, the 62-year-old woman carefully swung her legs over the side of the bed and stood. And there it was: A clamp tightened around the right side of her head. The pain was over her right ear, in her face and down the right side of her neck. She took a deep breath. Another day. Another headache.
She hadn’t been a headache person for most of her life. But that changed early in 2025 with these headaches that hit as soon as she got up in the morning. It was a pressure-like pain, always on the right side, and ibuprofen and acetaminophen barely touched it.
Given the severity of her pain, the nurse practitioner who was the woman’s primary care provider wondered if these were migraines. She prescribed a medication meant to stop this type of headache when taken as soon as the pain starts. But because it is unusual to start getting headaches at this age, and because the patient’s mother had suffered a ruptured brain aneurysm, she sent her for a head CT. It was a relief for the patient to hear that the CT was normal, but she needed to know the cause of her pain. She went to her eye doctor to find out if she needed a new glasses prescription. She did, but that didn’t help. Her boss installed a shade over her desk to cut the glare from the fluorescent light. She was grateful, but the headaches were unrelenting.
Her P.C.P., still wondering if this could be an aneurysm, referred her to a local neurosurgeon. Hearing her story, the physician assistant in the neurosurgery practice agreed that these probably were migraines and prescribed an additional medication, propranolol, to be taken daily. But the possibility of an aneurysm remained, so she also ordered an M.R.I. of her brain and a CT scan of the blood vessels in her brain. The woman had the two studies a couple of weeks later. There was no aneurysm. Her vessels were normal. Her brain, however, was not.
A Worrisome Explanation
When the patient saw the M.R.I. result, she was alarmed. She had, the report said, something called brain sag. She wasn’t sure what that was, but it sounded bad. She left a message for the P.A., and when she didn’t hear back, she got scared. She called her P.C.P. and was referred to another neurosurgeon, this time at the Cleveland Clinic.
The patient’s first thought when she saw Dr. Mohammed Abdulrazzak at the Cleveland Clinic branch in Canton, Ohio, was that he was too young to be a doctor, much less a neurosurgeon. He introduced himself, then sat in the chair across from hers. “I hear you have a headache,” he said. She felt a sense of real interest from him as she told her story. She explained how terrible her headaches were when she was upright, when she laughed or even spoke. When she sneezed, the pain was unbelievable. And recently the headaches seemed to be affecting her memory as well. She had to write things down to keep herself from forgetting. The migraine medications did help, but the only thing that made her headaches almost completely subside was lying down. When she said this, she thought she saw just a hint of excitement in the young doctor’s eyes.
Brain sag, Abdulrazzak explained, was usually caused by the loss of some of the spinal fluid that cushions and supports the brain. When standing, gravity pulls the already-depleted fluid farther downward, stretching the pain-sensitive membranes and structures around the brain. Lying down eases that stretch immediately. The woman’s story was classic for the diagnosis: a headache that responds to posture almost like a light switch, in a way that tension headaches and migraines rarely do.
Abdulrazzak pointed to the black and white curves of her brain on the M.R.I. Even when she was lying down, her cerebellum was so low that it was almost touching the skull near the foramen magnum, the hole through which the spinal column emerged. That’s why her brain appeared to be sagging. He asked the patient if she had had any recent surgery or trauma. She hadn’t. Abdulrazzak wasn’t surprised. Many of these leaks are spontaneous, the cause never discovered.
The hardest part of this disease was finding the leak. In the necessary test, called a myelogram, contrast is injected into the space around the spinal column and a CT scan captures where it leaks out.
The test was awful. The increased pressure caused by the injection of the contrast made her whole head ache. She waited anxiously for the results. No leak was seen. But Abdulrazzak was sure there was one. There was another study, he told her, only recently available, that would give them a better image. They could give her general anesthesia so she wouldn’t feel the pressure from the injected contrast. The woman considered this possibility then shook her head. The headaches were manageable with the medications, she said. She asked if she could just wait and see what happened. Abdulrazzak assured her she could, and told her to come back in a few months.
Another Test
She felt OK for awhile. But just over a year after the headaches started, the medications suddenly stopped working. Getting out of bed in the morning was almost torture, and some days she had to call in sick and spend the entire day in bed.
Her best friend was distressed to see the woman suffer so much. On weekends, the women and their husbands often went to listen to music in the local bars. But the last time they went out, the woman had to leave. The music, the crowd — it was all just too much for her. These days her friend couldn’t help noticing how tired she looked. She was pale. She had dark circles under her eyes. And she was so forgetful. The way she repeated herself reminded the friend of her own grandmother who had Alzheimer’s.
“You’ve got to go back to that doctor and see what he can do,” the friend exclaimed one evening when the woman was in the grips of a really bad headache.
Her friend went with her a few weeks later to see Abdulrazzak, who arranged the second test. In it, the patient lay on her right side. Once she was sedated, a catheter was inserted into the base of the sac containing the spinal cord, and contrast was injected. Then the table was tilted so that the contrast could flow upward, highlighting the entire spinal column. And there it was — the leak. A thin trickle of contrast filled one of the tiny veins leading away from the sac at the level of the 10th thoracic vertebra, just above the bottom of the rib cage.
Two weeks later, Abdulrazzak inserted a tiny catheter into the woman’s thigh. He slowly threaded it up the vein, carefully navigating toward the tiny vessel the spinal fluid was leaking into. He guided his way using a viewable X-ray called a fluoroscope to find the exact spot. Once he was at the site of the leak, he injected a material to completely seal off the vein.
When the patient woke up, Abdulrazzak told her that she would have a headache for a week or so. Her body had increased the amount of spinal fluid it made trying to compensate for the leak. Now that the leak was sealed, her body would have to reduce its spinal fluid output, and that would take a little time.
She went home the next day, and she did have a headache. But as promised, over the next couple of weeks, the pain gradually disappeared. Her memory started to improve. The real test, she knew, would come when she and her friend and their husbands went out. So, some six weeks after her procedure, the two couples struck out for one of their favorite places. She hadn’t had a headache for weeks, and worried the thunderous music would bring it all back. They found a seat as far from the speakers as they could get. Finally the band came out and picked up their instruments. The woman’s heart raced. But once the lead guitarist struck his first chord, quickly followed by bass, drums and keyboard, she sensed that her headaches were gone for good and life could finally return to normal.
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