A 60-year-old woman with diabetes presented with a six-month history of a subjective feeling of bilateral leg unsteadiness and leg fatigue that was relieved by sitting or leaning. She denied any other orthostatic features, including head pain. Neurological examination was notable for a preference for a widened stance and a palpable tremor of the lower extremities on standing. Brain MRI with and without gadolinium revealed diffuse smooth pachymeningeal enhancement, venous distension, a right subdural collection, and a 7 mm tonsillar herniation, findings suggestive of SIH. On further inquiry, the patient continued to deny head pain or other orthostatic features but did report mild left-sided tinnitus and muffled hearing. The patient was managed with a CT-guided high-volume, untargeted epidural blood patch.  After four weeks, the patient’s subjective leg unsteadiness significantly improved, with the resolution of orthostatic tremor taking place over several months. A repeat brain MRI with and without gadolinium confirmed the resolution of abnormal findings.

SIH without head pain is uncommon and SIH presenting as orthostatic tremor is rare. Secondary movement disorders may be provoked by SIH due to the loss of hydrostatic support that occurs with a spinal CSF leak, which results in brain sag and compression of the basal ganglia and associated connections. Brain neuroimaging can increase suspicion of SIH in patients who do not have classic clinical features of SIH.