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

  • 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
  • Risk Factors
  • 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)
  • 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
  • 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
    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
  • Course
  1. Untreated Headache lasts 4 to 8 days (up to 14 days)
  • 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]
  • 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]