II. Epidemiology
- Occurs in 10 to 30% of patients after Lumbar Puncture (less common with smaller gauge, blunt needles)
- Spontaneous Intracranial Hypotension (with cough or sneeze) occurs in 5 per 100,000
- Rare under age 13 years old or over age 60 years old
III. Risk Factors
- Migraine Headache history
- Postpartum women ages 18 to 30 years old (following spinal Anesthetic or Epidural Anesthesia)
- Low Body Mass Index (inconsistent association)
IV. Pathophysiology
- Background
- Body is capable of producing 500 cc CSF/day but relies on adequate vascular system substrate
- Decreased CSF results in positional Headache
- Reflex vasodilation of meningeal vessels in response to decreased CSF Pressure
- Intracranial structures that are pain sensitive are under greater traction in upright position
- Continued CSF Leakage through dural hole at Lumbar Puncture site
- Intracranial traction on Meninges
- Low CSF Pressure
- Idiopathic Intracranial Hypotension (Spontaneous Intracranial Hypotension)
- Dural tear (typically along Vertebral spine) secondary to coughing, straining in labor
- Similar presentation to Spinal Headache (positional)
V. Symptoms:
-
Headache Location
- Frontal, Occipital or diffuse
-
Headache Characteristics
- Severe dull or throbbing
-
Headache Timing
- Follows Lumbar Puncture within 4 days
- May also occur spontaneously with coughing or sneezing
- Headache provocative maneuvers (orthostatic, postural or positional Headache)
-
Headache palliative factors
- Relieved by lying supine (Headache improves within 30 minutes of lying supine)
- Associated factors in severe Headache
VI. Signs
- Mild neck stiffness
- Normal Neurologic Exam
- Sinus Bradycardia
VII. Diagnosis
- Orthostatic Headache with CSF Leak or procedure
- Lumbar Puncture with opening pressure of <6 cm H2O
- No other pathologic cause
VIII. Imaging
- Typically not indicated in post-dural Headache
- Consider in suspected Spontaneous Intracranial Hypotension
- MRI with gadolinium contrast findings suggestive of Spontaneous Intracranial Hypotension (93% have at least one finding)
- Subdural fluid collection
- Pachymeninges enhancement
- Venous engorgement
- Pituitary hyperemia and sagging
- Brain downward displacement
IX. Management
- First Line: Conservative Measures
- Bed rest
- Maintain hydration
- Caffeine
- Other measures with less evidence for benefit
- Cosyntropin
- Synthetic ACTH administration stimulates adrenal production of CSF
- Exercise caution in Diabetes Mellitus
- Hakim (201) Anesthesiology 113(2):413-20 +PMID:20613476 [PubMed]
- Sumatriptan
- Variable evidence for effect
- Cosyntropin
- References
- Ona (2015) Cochrane Database Syst Rev (7):CD007887 +PMID: 26176166
- Next: Invasive Measures (refractory Headache after 24-48 hours of conservative measures)
- Next: Persistent Refractory Spinal Headache
- Repeat Epidural Blood Patch
- Continuous intrathecal saline infusion
- Epidural catheter at L2-L3
- Saline infusion at 20 cc/hour
- Maximum duration: 72 hours
X. Course
XI. Prevention
- Use a small gauge spinal needle (20 to 22) for Lumbar Puncture (LP)
- Use non-Traumatic, blunt, non-cutting needle for LP
- Insert LP needle bevel parallel to dural fibers
- Replace the spinal needle stylet before removal
- Minimize number of Lumbar Puncture attempts
- Patients should avoid straining, bending or heavy lifting after Lumbar Puncture
-
Intravenous Fluids prior to Lumbar Puncture
- Does not decrease Spinal Headache Incidence but may decrease duration
- Eldevik (1978) Radiology 129(3): 715-6 +PMID:152937 [PubMed]
- Bedrest for at least 1 hour following Lumbar Puncture does not appear to affect postdural headache Incidence
XII. References
- Claudius and Darras in Herbert (2018) EM:Rap 18(11)12-3
- Goetz (1999) Clinical Neurology, Saunders, p. 1100
- Mason and Grock in Herbert (2017) EM:Rap 17(5): 4-5
- Swaminathan, Rezaie and Spampinato in Herbert (2015) EM:Rap 15(5): 2-3
- Bart (1978) Anesthesiology 48:221-3 [PubMed]
- Grock (2017) Ann Emerg Med 69(5): 661-3 [PubMed]
- Lybecker (1995) Acta Anaesthesiol Scand 39:605-12 [PubMed]