Supplementary Material for: A Possible Newly Defined and Treatable Secondary Cause of Early Morning Wake-Up Headaches in an Older Hypermobile Woman: Nutcracker Physiology with Spinal Epidural Venous Congestion

Introduction
Left renal vein compression (nutcracker physiology) with secondary spinal epidural venous congestion is a newly recognized cause of daily persistent headache. Presently only women with underlying symptomatic hypermobility issues appear to develop headache from this anatomic issue. The hypothesized etiology is an abnormal reset of the patient’s cerebrospinal fluid (CSF) pressure to an elevated state. Headaches that occur during sleep can have a varied differential diagnosis, one of which is elevated CSF pressure. We present the case of an older woman who began to develop severe wake-up headaches at midnight. She was found to have left renal vein compression and spinal epidural venous congestion on imaging. After treatment with lumbar vein coil embolization, which alleviated the spinal cord venous congestion, her headaches alleviated.
Case Presentation
A 61-year-old woman with a history of hypermobile Ehlers-Danlos syndrome, began to be awakened with severe head pain at midnight at least several times per week. The headache was a holocranial, pressure sensation, which worsened in the supine position. The headaches were mostly eliminated with acetazolamide. Because of her hypermobility issues and pressure-like headache she was investigated for underlying nutcracker physiology and spinal epidural venous congestion. This was confirmed using magnetic resonance (MR) angiography and conventional venography, and after lumbar vein coil embolization her wake-up headaches ceased.
Conclusion
The case report suggests a possible new underlying and treatable cause for early morning, wake-up, headaches: nutcracker physiology with secondary spinal epidural venous congestion. The case expands on the clinical headache presentation of nutcracker physiology.

引言
左侧肾静脉压迫（即坚果夹生理现象）继发性脊髓硬脊膜静脉淤血是新近识别的持续性日常头痛病因之一。目前，只有存在潜在症状性过度活动问题的女性患者似乎会因为这一解剖问题而出现头痛。假设的发病机制是患者脑脊液（CSF）压力异常重置至升高状态。睡眠期间发生的头痛可能具有多种不同的诊断可能性，其中之一即为CSF压力升高。我们报告了一例老年女性患者，她开始于午夜时分出现严重的觉醒头痛，每周至少发生几次。头痛表现为全头部的压迫感，在仰卧位时加重。头痛大部分可以通过乙酰唑胺消除。由于她存在过度活动问题和压迫性头痛，因此对其进行了潜在坚果夹生理和脊髓硬脊膜静脉淤血的检查。这一诊断通过磁共振血管造影和常规静脉造影得到证实，经过腰静脉线圈栓塞治疗后，她的觉醒头痛得以缓解。
病例报告
一位61岁的女性患者，既往有过度活动型埃-当二氏综合征病史，开始每隔几周于午夜时分被严重的头痛痛醒。头痛表现为全头部的压迫感，在仰卧位时加剧。头痛大部分可以通过乙酰唑胺消除。由于她的过度活动问题和压迫性头痛，她接受了潜在坚果夹生理和脊髓硬脊膜静脉淤血的检查。这一诊断通过磁共振血管造影和常规静脉造影得到证实，经过腰静脉线圈栓塞治疗后，她的觉醒头痛停止。
结论
本病例报告提出了一种可能的新发且可治疗的清晨觉醒头痛病因：坚果夹生理继发性脊髓硬脊膜静脉淤血。该病例扩展了坚果夹生理的临床头痛表现。