We present a 65 year old lady with 30 year history of chronic daily headache without postural changes after a road traffic accident presented with three months history of postural head and upper limb tremor, progressive ataxia, dizziness, mild confusion and few falls. She had worsening of epilepsy with partial status prompting acute hospital admission. Symptoms exacerbated on standing and she preferred lying down most of the time. Previous history of temporal lobe epilepsy and Anterior Cervical Decompression and Fusion.

Examination: She had a head tremor which exaggerated on upright posture along with truncal ataxia, gait ataxia and dysmetria bilaterally. Head and upper limb tremor improved on lying down position without any change to her headache. She did not have any other pyramidal or extrapyramidal features. Increasing Lamotrigine dosage and adding Levetiracetam helped control seizures.

CT head and two MRI head scan showed radiological features of low CSF pressure syndrome. There were small bilateral subdural hygromas, uniform meningeal enhancement thought the cranium extending to cervical spinal cord dura, and dural-venous-sinus engorgement. MRI spine did not show any CSF leak. CSF opening pressure was 12.0 cm of H20 with normal constituents.

A blind blood patch was performed with excellent outcome, her postural tremors, chronic headache and gait ataxia improved when reviewed at week one.

Low CSF pressure syndrome presenting as Movement disorder is rare and recognising atypical presentation is cardinal.