Headache

Spinal Headache

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

  • See Also
  1. Headache
  2. Headache Evaluation
  • 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
  • Risk Factors
  1. Migraine Headache history
  2. Postpartum women ages 18 to 30 years old (following spinal Anesthetic or Epidural Anesthesia)
  3. Low Body Mass Index
  • 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)
  • Symptoms
  1. Headache Location
    1. Frontal, Occipital or diffuse
  2. Headache Characteristics
    1. Severe dull or throbbing
  3. Headache Timing
    1. Follows Lumbar Puncture within 4 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
    3. Tinnitus
  • Signs
  1. Mild neck stiffness
  2. Normal Neurologic Exam
  3. Sinus Bradycardia
  • Diagnosis
  1. Orthostatic Headache with CSF Leak or procedure
  2. Lumbar Puncture with opening pressure of <6 cm H2O
  3. No other pathologic cause
  • Imaging
  1. Typically not indicated in post-dural Headache
    1. Consider in suspected Spontaneous Intracranial Hypotension
  2. 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
  • Management
  1. 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
  2. Next: Invasive Measures (refractory Headache after 24-48 hours of conservative measures)
    1. Epidural Blood Patch
  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
  • 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
  • Prevention
  1. Use a small gauge spinal needle (20 to 22) for Lumbar Puncture
  2. Insert LP needle bevel parallel to dural fibers
  3. Replace the spinal needle stylet before removal
  4. Minimize number of Lumbar Puncture attempts
  5. Patients should avoid straining, bending or heavy lifting after Lumbar Puncture
  6. 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]
  7. 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]
  • 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]