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)
- More common in women
- 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
-
Headache Characteristics
- Severe dull or throbbing Headache
-
Headache Timing
- Follows Lumbar Puncture within 4 to 5 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. Differential Diagnosis
- See Headache Causes
- Post-Dural Puncture Complications
- See Lumbar Puncture
- Spinal Epidural Hematoma
- Iatrogenic Meningitis (rare)
- Pregnancy-Related Complications (for women who delivered with epidural or spinal Anesthetic)
- See Postpartum Headache
- Pregnancy Induced Hypertension (PIH, Preeclampsia) is always in the Postpartum Headache differential
VIII. Diagnosis
- Orthostatic Headache with CSF Leak or procedure
- Lumbar Puncture with opening pressure of <6 cm H2O
- No other pathologic cause
IX. Imaging
- Typically not indicated in post-dural Headache
- Indications
- Suspected Spontaneous Intracranial Hypotension
- Headache not typical for post-dural cause (non-orthostatic, onset >5 days after dural puncture)
- Focal neurologic deficits
- Visual changes
- Altered Level of Consciousness
- 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
X. Management
- First Line: Conservative Measures
- Bed rest
- Maintain oral hydration
- Oral Non-Opioid Analgesics (NSAIDS, Acetaminophen)
- Caffeine
- Efficacy
- Caffiene dosing is high and varies widely (300 to 900 mg/day)
- Caffeine 300 mg orally
- See Caffeine for Caffeine amounts in various sources
- Camann (1990) Anesth Analg 70(2): 181 +PMID:2405733 [PubMed]
- Caffeine Benzoate 500 mg in 1 L IV over 2 hours
- 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: Epidural Blood Patch Indications
- See Epidural Blood Patch
- Refractory Headache after 24-48 hours of conservative measures
- Impaired Activities of Daily Living
- Associated neurologic symptoms
- 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
XI. Course
XII. Prevention
- Use a small gauge spinal needle (20 to 22) for Lumbar Puncture (LP)
- Use non-Traumatic, blunt, non-cutting needle for Lumbar Puncture
- 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
XIII. Complications
- Cerebral Venous Sinus Thrombosis
- Subdural Hematoma
- Cranial Nerve dysfunction
- Chronic Headache
- Persistent neck or back pain
XIV. 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]
- Uppal (2023) JAMA Netw Open 6(8):e2325387 +PMID: 37581893 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
Concepts | Sign or Symptom (T184) |
MSH | D006261 |
SnomedCT | 445511002 |
French | Céphalée orthostatique |
German | Orthostatischer Kopfschmerz |
Italian | Cefalea ortostatica |
English | Headache, Orthostatic, Headaches, Orthostatic, Orthostatic Headaches, Orthostatic headache, Orthostatic headache (finding), orthostatic headache, orthostatic headaches, Orthostatic Headache |
Spanish | cefalea ortostática (hallazgo), cefalea ortostática |
Czech | ortostatická bolest hlavy |
Norwegian | Ortostatisk hodepine |
Ontology: Post-Dural Puncture Headaches (C0751188)
Definition (MSH) | A secondary headache disorder attributed to low CEREBROSPINAL FLUID pressure caused by SPINAL PUNCTURE, usually after dural or lumbar puncture. |
Concepts | Sign or Symptom (T184) |
MSH | D051299 |
SnomedCT | 230479008, 111493001, 398987004 |
English | PDPH-Postdural punct headache, Post-dural puncture headache, Post-Dural Puncture Headache [Disease/Finding], postdural puncture headache, dural headaches post puncture, post dural puncture headache, dural headache post puncture, post-dural puncture headache, PDPH - Post dural puncture headache, Post dural puncture headache, Post dural puncture headache (disorder), Post-Dural Puncture Headaches, Headache, Post-Dural Puncture, Headaches, Post-Dural Puncture, Post Dural Puncture Headache, Post-Dural Puncture Headache, Headache, Postdural Puncture, Headaches, Postdural Puncture, Postdural Puncture Headache, Postdural Puncture Headaches |
Swedish | Postdural punkteringshuvudvärk |
Czech | bolest hlavy po spinální punkci |
Finnish | Punktiopäänsärky |
Russian | GOLOVNAIA BOL' V REZUL'TATE POSTDURAL'NOI PUNKTSII, ГОЛОВНАЯ БОЛЬ В РЕЗУЛЬТАТЕ ПОСТДУРАЛЬНОЙ ПУНКЦИИ |
French | CPPD (Céphalée Post-Ponction Durale), Céphalée post-ponction durale (CPPD), CPPDM, Céphalée post-ponction de la dure-mère, Céphalée post-ponction durale |
Polish | Ból głowy po nakłuciu rdzeniowym, Ból głowy po nakłuciu opony twardej, Ból głowy po nakłuciu lędźwiowym |
Japanese | 腰椎穿刺後頭痛, 頭痛-硬膜穿刺後, 硬膜穿刺後頭痛, 頭痛-腰椎穿刺後 |
Norwegian | Hodepine etter duralpunksjon, Postspinalpunksjonshodepine, Hodepine etter spinalpunksjon, Hodepine etter lumbalpunksjon |
Portuguese | Cefaleia Pós-Punção Dural, Cefalalgia Pós-Punção Lombar, Cefalgia Pós-Punção Dural, Cefalalgia Pós-Punção Dural, Cefalgia Pós-Punção Lombar, Cefaleia Pós-Punção Lombar |
Spanish | cefalea posterior a la punción dural (trastorno), cefalea posterior a la punción dural, Cefalea Pospunción de la Duramadre |
German | Kopfschmerz nach Durapunktion, Postpunktioneller Kopfschmerz, Postspinaler Kopfschmerz |
Italian | Cefalea da puntura durale, Cefalea post-puntura durale |
Ontology: Idiopathic intracranial hypotension (C3839515)
Concepts | Disease or Syndrome (T047) |
SnomedCT | 700219009 |
English | Idiopathic intracranial hypotension (disorder), Idiopathic intracranial hypotension |
Ontology: Postural headache (C3853085)
Concepts | Sign or Symptom (T184) |
SnomedCT | 445491000124104 |
English | Postural headache (finding), Postural headache |