Spinal Headache

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

Migraine Headache history
Postpartum women ages 18 to 30 years old (following spinal anesthetic or Epidural Anesthesia)
Low Body Mass Index

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
Continued CSF leakage through dural hole at Lumbar Puncture site
1. Intracranial traction on Meninges
2. Low CSF Pressure
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)

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

Typically not indicated in post-dural Headache
1. Consider in suspected Spontaneous Intracranial Hypotension
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

First Line: Conservative Measures
1. Bed rest
2. Maintain hydration
3. Caffeine
  1. Effective in markedly reducing Headache at 1-4 hours
  2. Headache recurs in 30% of patients within 24 hours
  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]
4. 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
5. References
  1. Ona (2015) Cochrane Database Syst Rev (7):CD007887 +PMID: 26176166
Next: Invasive Measures (refractory Headache after 24-48 hours of conservative measures)
1. Epidural Blood Patch
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

Untreated Headache lasts 4 to 8 days (up to 14 days)
1. Consider CSF fistula if Headache persists longer than 14 days

Use a small gauge spinal needle (20 to 22) 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
1. Does not decrease Spinal Headache Incidence but may decrease duration
2. 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
1. Carbaat (1981) Lancet 2(8256): 1133-5 +PMID:6118577 [PubMed]
2. Arevalo-Rodriguez (2013) Cochrane Database Syst Rev 7:CD009199 +PMID:23846960 [PubMed]