Spinal Headache

Aka: Spinal Headache, Post-Lumbar puncture headache, Post-Dural Puncture Headache, Postdural Puncture Headache, Idiopathic Intracranial Hypotension, Spontaneous Intracranial Hypotension, Postural Headache, Orthostatic Headache

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II. Epidemiology

  1. Occurs in 10 to 30% of patients after Lumbar Puncture (less common with smaller gauge, blunt needles)
  2. Spontaneous Intracranial Hypotension (with cough or sneeze) occurs in 5 per 100,000
  3. Rare under age 13 years old or over age 60 years old

III. Risk Factors

  1. Migraine Headache history
  2. Postpartum women ages 18 to 30 years old (following spinal Anesthetic or Epidural Anesthesia)
  3. More common in women
  4. Low Body Mass Index (inconsistent association)

IV. Pathophysiology

  1. Background
    1. Body is capable of producing 500 cc CSF/day but relies on adequate vascular system substrate
    2. Decreased CSF results in positional Headache
      1. Reflex vasodilation of meningeal vessels in response to decreased CSF Pressure
      2. Intracranial structures that are pain sensitive are under greater traction in upright position
  2. Continued CSF Leakage through dural hole at Lumbar Puncture site
    1. Intracranial traction on Meninges
    2. Low CSF Pressure
  3. Idiopathic Intracranial Hypotension (Spontaneous Intracranial Hypotension)
    1. Dural tear (typically along Vertebral spine) secondary to coughing, straining in labor
    2. Similar presentation to Spinal Headache (positional)

V. Symptoms:

  1. Headache Location
    1. Frontal, Occipital or diffuse Headache
  2. Headache Characteristics
    1. Severe dull or throbbing Headache
  3. Headache Timing
    1. Follows Lumbar Puncture within 4 to 5 days
    2. May also occur spontaneously with coughing or sneezing
  4. Headache provocative maneuvers (orthostatic, postural or positional Headache)
    1. Sitting or standing (upright Posture)
    2. Head-shaking
    3. Coughing or sneezing
    4. Straining
    5. Jugular compression
  5. Headache palliative factors
    1. Relieved by lying supine (Headache improves within 30 minutes of lying supine)
  6. Associated factors in severe Headache
    1. Nausea or Vomiting
    2. Dizziness or Vertigo
    3. Subjective Hearing changes or Tinnitus
    4. Visual disturbance

VI. Signs

  1. Mild neck stiffness
  2. Normal Neurologic Exam
  3. Sinus Bradycardia

VII. Differential Diagnosis

  1. See Headache Causes
  2. Post-Dural Puncture Complications
    1. See Lumbar Puncture
    2. Spinal Epidural Hematoma
    3. Iatrogenic Meningitis (rare)
  3. Pregnancy-Related Complications (for women who delivered with epidural or spinal Anesthetic)
    1. See Postpartum Headache
    2. Pregnancy Induced Hypertension (PIH, Preeclampsia) is always in the Postpartum Headache differential

VIII. Diagnosis

  1. Orthostatic Headache with CSF Leak or procedure
  2. Lumbar Puncture with opening pressure of <6 cm H2O
  3. No other pathologic cause

IX. Imaging

  1. Typically not indicated in post-dural Headache
  2. Indications
    1. Suspected Spontaneous Intracranial Hypotension
    2. Headache not typical for post-dural cause (non-orthostatic, onset >5 days after dural puncture)
    3. Focal neurologic deficits
    4. Visual changes
    5. Altered Level of Consciousness
  3. MRI with gadolinium contrast findings suggestive of Spontaneous Intracranial Hypotension (93% have at least one finding)
    1. Subdural fluid collection
    2. Pachymeninges enhancement
    3. Venous engorgement
    4. Pituitary hyperemia and sagging
    5. Brain downward displacement

X. Management

  1. First Line: Conservative Measures
    1. Bed rest
      1. Often reduces Headache, but prolonged bedrest does NOT reduce Headache duration
    2. Maintain oral hydration
    3. Oral Non-Opioid Analgesics (NSAIDS, Acetaminophen)
    4. Caffeine
      1. Efficacy
        1. More effective for Headache in the first 24 hours after dural puncture
        2. Effective in markedly reducing Headache at 1-4 hours
        3. Headache recurs in 30% of patients within 24 hours
      2. Caffiene dosing is high and varies widely (300 to 900 mg/day)
        1. See Caffeine for adverse effects associated with high dose Caffeine
        2. Limit Caffeine to 300 mg/day in Lactation
      3. Caffeine 300 mg orally
        1. See Caffeine for Caffeine amounts in various sources
        2. Camann (1990) Anesth Analg 70(2): 181 +PMID:2405733 [PubMed]
      4. Caffeine Benzoate 500 mg in 1 L IV over 2 hours
        1. Sechzer (1978) Curr Ther Clin Exp 24:307-12 [PubMed]
    5. Other measures with less evidence for benefit
      1. Cosyntropin
        1. Synthetic ACTH administration stimulates adrenal production of CSF
        2. Exercise caution in Diabetes Mellitus
        3. Hakim (201) Anesthesiology 113(2):413-20 +PMID:20613476 [PubMed]
      2. Sumatriptan
        1. Variable evidence for effect
    6. References
      1. Ona (2015) Cochrane Database Syst Rev (7):CD007887 +PMID: 26176166
  2. Next: Epidural Blood Patch Indications
    1. See Epidural Blood Patch
    2. Refractory Headache after 24-48 hours of conservative measures
    3. Impaired Activities of Daily Living
    4. Associated neurologic symptoms
  3. Next: Persistent Refractory Spinal Headache
    1. Repeat Epidural Blood Patch
    2. Continuous intrathecal saline infusion
      1. Epidural catheter at L2-L3
      2. Saline infusion at 20 cc/hour
      3. Maximum duration: 72 hours

XI. Course

  1. Untreated Headache lasts 4 to 8 days (up to 14 days)
    1. Consider CSF fistula if Headache persists longer than 14 days
    2. Spontaneous CSF Leak related Headaches may persist up to 4 weeks

XII. Prevention

  1. Use a small gauge spinal needle (20 to 22) for Lumbar Puncture (LP)
  2. Use non-Traumatic, blunt, non-cutting needle for Lumbar Puncture
  3. Insert LP needle bevel parallel to dural fibers
  4. Replace the spinal needle stylet before removal
  5. Minimize number of Lumbar Puncture attempts
  6. Patients should avoid straining, bending or heavy lifting after Lumbar Puncture
  7. Intravenous Fluids prior to Lumbar Puncture
    1. Does not decrease Spinal Headache Incidence but may decrease duration
    2. Eldevik (1978) Radiology 129(3): 715-6 +PMID:152937 [PubMed]
  8. Bedrest for at least 1 hour following Lumbar Puncture does not appear to affect postdural headache Incidence
    1. Carbaat (1981) Lancet 2(8256): 1133-5 +PMID:6118577 [PubMed]
    2. Arevalo-Rodriguez (2013) Cochrane Database Syst Rev 7:CD009199 +PMID:23846960 [PubMed]

XIII. Complications

  1. Cerebral Venous Sinus Thrombosis
  2. Subdural Hematoma
  3. Cranial Nerve dysfunction
  4. Chronic Headache
  5. Persistent neck or back pain

XIV. References

  1. Claudius and Darras in Herbert (2018) EM:Rap 18(11)12-3
  2. Goetz (1999) Clinical Neurology, Saunders, p. 1100
  3. Mason and Grock in Herbert (2017) EM:Rap 17(5): 4-5
  4. Swaminathan, Rezaie and Spampinato in Herbert (2015) EM:Rap 15(5): 2-3
  5. Bart (1978) Anesthesiology 48:221-3 [PubMed]
  6. Grock (2017) Ann Emerg Med 69(5): 661-3 [PubMed]
  7. Lybecker (1995) Acta Anaesthesiol Scand 39:605-12 [PubMed]
  8. Uppal (2023) JAMA Netw Open 6(8):e2325387 +PMID: 37581893 [PubMed]

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