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Spinal HeadacheAka: Post-Lumbar puncture headache, Postdural Puncture Headache

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  1. See Also
    1. Headache
    2. Headache Evaluation
  2. Epidemiology
    1. Occurs in 10 to 30% of patients after Lumbar Puncture
  3. Risk Factors
    1. Migraine Headache history
  4. Pathophysiology
    1. Continued CSF leakage through dural hole at LP site
      1. Intracranial traction on meninges
      2. Low CSF Pressure
  5. Symptoms:
    1. Headache Location: Frontal, Occipital or diffuse
    2. Headache Characteristics: Severe dull or throbbing
    3. Headache Timing: Follows Lumbar Puncture within 4 days
    4. Headache provocative maneuvers
      1. Sitting or standing (upright Posture)
      2. Head-shaking
      3. Coughing or sneezing
      4. Straining
      5. Jugular compression
    5. Headache relieved by lying supine
    6. Associated factors in severe Headache
      1. Nausea or Vomiting
      2. Dizziness
      3. Tinnitus
  6. Signs
    1. Mild neck stiffness
    2. Normal Neurologic Exam
    3. Sinus Bradycardia
  7. Diagnosis
    1. Orthostatic Headache with CSF leak or procedure
    2. No other pathologic cause
  8. Management
    1. First Line
      1. Bed rest
      2. Maintain hydration
      3. Caffeine Benzoate 500 mg in 1 L IV over 2 hours
      4. Blood Patch
    2. Refractory Spinal Headache
      1. Repeat 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
  9. Course
    1. Untreated Headache lasts 4 to 8 days (up to 14 days)
  10. Prevention
    1. Use a small gauge spinal needle (20 to 22)
    2. Insert needle parallel to dural fibers
  11. References
    1. Goetz (1999) Clinical Neurology, Saunders, p. 1100
    2. Bart (1978) Anesthesiology 48:221
    3. Lybecker (1995) Acta Anaesthesiol Scand 39:605

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