II. Epidemiology

  1. Occurs in 10 to 30% of patients after Lumbar Puncture

III. Risk Factors

IV. Pathophysiology

  1. Continued CSF leakage through dural hole at LP site
    1. Intracranial traction on Meninges
    2. Low CSF Pressure
  2. Idiopathic 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
  2. Headache Characteristics
    1. Severe dull or throbbing
  3. Headache Timing
    1. 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 palliative factors
    1. Relieved by lying supine
  6. Associated factors in severe Headache
    1. Nausea or Vomiting
    2. Dizziness
    3. Tinnitus

VI. Signs

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

VII. Diagnosis

  1. Orthostatic Headache with CSF leak or procedure
  2. No other pathologic cause

VIII. Management

  1. First Line
    1. Bed rest
    2. Maintain hydration
    3. Blood Patch
    4. 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]
  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

IX. Course

  1. Untreated Headache lasts 4 to 8 days (up to 14 days)

X. Prevention

  1. Use a small gauge spinal needle (20 to 22)
  2. Insert needle parallel to dural fibers
  3. 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]
  4. 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]

XI. References

  1. Swaminathan, Rezaie and Spampinato in Herbert (2015) EM:Rap 15(5): 2-3
  2. Goetz (1999) Clinical Neurology, Saunders, p. 1100
  3. Bart (1978) Anesthesiology 48:221-3 [PubMed]
  4. Lybecker (1995) Acta Anaesthesiol Scand 39:605-12 [PubMed]

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