Postdural Puncture Headache

Background

• Postdural puncture headache is a positional headache developing within 5 days of dural puncture, caused by loss of cerebrospinal fluid (CSF) and other factors.
• Pain from postdural puncture headache is typically severe. Headache is often accompanied by other symptoms including nausea, hearing impairment, sensitivity to light, and/or neck stiffness.
• Postdural puncture headache usually resolves spontaneously within 1-2 weeks.
• Overall incidence of postdural puncture headache following neuraxial procedures is reported to range from 6%-36%.

Evaluation

• Suspect postdural puncture headache in patient with positional headache occurring following dural puncture.
• Diagnosis of postdural puncture headache can usually be made based on the clinical presentation.
• Diagnostic criteria for postdural puncture headache:
  • headache developing within 5 days of dural puncture
  • orthostatic headache caused by low cerebrospinal fluid (CSF) pressure after dural puncture has been performed
  • accompanying symptoms may include neck pain, tinnitus, hearing changes, photophobia, and/or nausea
  • headache resolves either spontaneously within 2 weeks or after sealing of the leak with an autologous epidural lumbar blood patch
• Diagnostic testing that can help confirm diagnosis and/or rule out other causes of headache includes imaging studies such as:
  • magnetic resonance imaging (MRI) of brain and spine to identify signs of low CSF pressure and CSF leak
  • computed tomography or MRI to rule out alternate causes of headache

Management

• Inform patient that postdural puncture headache is typically self-limiting.
• Offer conservative treatment options and supportive medications as first-line approach, including:
  • horizontal positioning (bed rest) to alleviate pain
  • analgesics such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs)
  • antiemetics for management of associated nausea
  • hydration
• Offer pharmacological treatment or epidural blood patch for postdural puncture headache that is not controlled by conservative treatment.
  • Pharmacological options include:
    • methylxanthine derivatives including:
      • caffeine (300 mg orally or 500 mg IV)
      • theophylline 250-400 mg orally
      • aminophylline 250 mg IV
    • gabapentinoids including:
      • gabapentin 300 mg orally 3 times daily
      • pregabalin 100 mg orally 3 times daily
    • neostigmine 20 mcg/kg IV plus atropine 10 mcg/kg IV over 5 minutes every 8 hours
    • nebulized dexmedetomidine 1 mcg/kg inhaled twice daily
    • hydrocortisone 100 mg/2 mL IV every 8 hours for 48 hours
  • Epidural blood patch for moderate-to-severe headache involves 20-30 mL of autologous blood injected slowly into epidural space through epidural needle, typically at or above spinal level of original postdural puncture.
• Other more invasive options for moderate-to-severe headache include:
  • nerve block including:
    • greater occipital nerve block
    • sphenopalatine ganglion nerve block (evidence is limited)
  • other options including saline, dextran 40, or hydroxyethyl injections (but evidence is limited)

Prevention

• Use atraumatic (pencil point) needles when possible for lumbar puncture as they are associated with decreased risk of postdural puncture headache.
• Consider other procedural factors which may decrease risk of postdural puncture headache including:
  • lateral decubitus positioning of patient
  • reinsertion of stylet before needle removal
  • if using traumatic needle:
    • using thinner gauge needle
    • using parallel bevel orientation for insertion
• Avoid bed rest following lumbar puncture when possible. Bed rest may increase risk of postdural puncture headache.
• IV medications with evidence for efficacy for prevention of postdural puncture headache include:
  • cosyntropin 1 mg
  • ondansetron 0.15 mg/kg
  • aminophylline 250 mg
• Prophylactic epidural blood patch may also reduce the incidence of postdural puncture headache following epidural anesthesia, but not routinely recommended.