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Post-Dural Puncture Headache

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Background

  • Known complication of diagnostic lumbar puncture, following spinal anesthesia, or from unintentional dural puncture (UDP) during epidural insertion attempt

    • ~1/100 to 1/200 risk following spinal/epidural anesthesia

  • Headache usually develops 12-48 hrs after dural puncture (up to 5 days after); usually resolves spontaneously w/in 1-2 weeks

  • Headache is positional (worse when upright, better when supine), bilat, & usually frontal or occipital

  • May be accompanied by neck stiffness, photophobia, nausea, or subjective hearing changes (tinnitus, hypoacusia)

  • Thought to be d/t CSF leakage through dural hole causing CSF or intracranial hypotension

  • Risk factors: female sex, pregnancy, age (18-50), needle type (cutting > pencil point), larger needle size, needle inserted w/ bevel perpendicular to long axis of spine > parallel, operator inexperience; may have ↑ risk if stylet not reinserted prior to needle withdrawal

  • Important to rule out other more sinister cause of headache --> thorough history, physical examination

    • Consider urgent imaging (CT/MRI) +/- neuro consult if dx unclear, fever/chills, neuro signs, seizures, ↓ LOC, or if 2 EBPs ineffective

 

Management

  • Prevention of PDPH - insufficient evidence to provide clear guidance

    • consider injecting ~10 mls of preservative free NS into subarachnoid space if UDP

    • can also consider placing an intrathecal catheter x 24 hrs

      • must take measures to ensure that medications are not inadvertently injected into catheter

  • Conservative mgt

    • Bed rest, rehydration, abdominal binders

    • Oral caffeine

    • Analgesics (Acetaminophen, NSAIDs, opioids prn)

  • Epidural blood patch (EBP) - if conservative measures fail or headache is debilitating

    • 65-98% effective after 1 treatment; can repeat if necessary

    • Contraindications same as those for neuraxial anesthetic techniques

  • Sphenopalatine ganglion or greater occipital nerve block may provide symptomatic relief

 

References:

A Sabharwal, MBChB FRCA, GM Stocks, BSc MB BS FRCA, Postpartum headache: diagnosis and management, Continuing Education in Anaesthesia Critical Care & Pain, Volume 11, Issue 5, October 2011, Pages 181–185, https://doi.org/10.1093/bjaceaccp/mkr025

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ASA Statement on Post-Dural Puncture Headache Management (Approved October 13, 2021). Available at: https://www.asahq.org/standards-and-guidelines/statement-on-post-dural-puncture-headache-management

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