II. 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

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 (Spontaneous 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
    2. May also occur spontaneously with coughing or sneezing
  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. Lumbar Puncture with opening pressure of <6 cm H2O
  3. No other pathologic cause

VIII. 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

IX. 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

X. Course

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

XI. 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]

XII. References

  1. Goetz (1999) Clinical Neurology, Saunders, p. 1100
  2. Mason and Grock in Herbert (2017) EM:Rap 17(5): 4-5
  3. Swaminathan, Rezaie and Spampinato in Herbert (2015) EM:Rap 15(5): 2-3
  4. Bart (1978) Anesthesiology 48:221-3 [PubMed]
  5. Lybecker (1995) Acta Anaesthesiol Scand 39:605-12 [PubMed]

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

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