Postdural Puncture Headache: Guidelines From a Multisociety, International Working Group

Postdural puncture headache is caused by low cerebrospinal fluid pressure that occurs within 5 days of an accidental or intentional lumbar puncture. A multisociety, international working group released guidelines on the evaluation and treatment of postdural puncture headache.

Postdural puncture headache should be suspected anytime a headache or neurologic symptoms occur within 5 days of a neuraxial procedure. Typical symptoms include neck stiffness; pain in the cervical, thoracic, or lumbar spine; subjective hearing symptoms; visual disturbances; and vertigo. Symptoms most often improve when lying flat. Headaches, which are common after childbirth, are only sometimes due to postdural puncture.

Postdural puncture headache is more common in younger patients, especially females. This type of headache may be more likely in patients with a history of headaches and less likely to occur in people who smoke cigarettes. The likelihood of postdural puncture headache does not seem to be associated with body weight.

Brain imaging should be considered in patients with a nonorthostatic headache that starts more than 5 days after suspected dural puncture or after a previous orthostatic headache. Neuroimaging should be considered in patients with focal neurologic defects, visual changes, or alterations in consciousness to look for an alternate diagnosis, especially in the post-partum period.

When performing lumbar puncture, use of noncutting spinal needles decreases risk of postdural puncture headache. If cutting needles are used, insertion with the bevel parallel to the long axis of the spine appears to decrease risk. For all needle types, smaller needles seem to have less risk.

After an inadvertent dural puncture during attempted epidural catheter placement, intrathecal catheters may not decrease risk of postdural puncture headache but can be used to provide anesthesia or analgesia. Prophylactic epidural blood patches after inadvertent dural puncture do not appear to prevent postdural puncture headache and are not recommended. The benefit of prophylactic bed rest in reducing severity of postdural puncture headache is uncertain.

Medical Treatment

For all patients with postdural puncture headache, regular analgesia using acetaminophen and nonsteroidal anti-inflammatory drugs is the primary recommended treatment. Short-term opioid therapy can be considered if other medications are ineffective, but long-term opioid therapy is not recommended.

For headache symptoms within the first 24 hours, up to 900 mg per day of caffeine is recommended. If the patient is breastfeeding, caffeine should be limited to no more than 300 mg per day. Oral hydration is sufficient in most cases, but intravenous fluids may be needed if oral hydration cannot be maintained.

Bed rest can be used for control of symptoms, but there is no evidence that prolonged bed rest affects the duration of postdural puncture headache. Evidence does not support using hydrocortisone, theophylline, triptans, adrenocorticotropic hormone, neostigmine (Bloxiverz), atropine, methylergonovine (Methergine), or gabapentin. There is also no evidence of benefit from abdominal binders and aromatherapy.

Epidural Blood Patches

Epidural blood patches are recommended when postdural puncture headache is refractory to conservative therapy, impairs activities of daily living, or presents with neurologic symptoms. Treatment leads to complete headache remission in at least one-third of cases. Repeat blood patching may be necessary, especially if the initial procedure is performed within 48 hours of the dural puncture. When backache or neurologic complications occur or persist after blood patching, another diagnosis should be considered.

An epidural blood patch involves injecting autologous blood at or one space below the site of dural puncture, if known. Although the optimal volume of blood to inject is unknown, volumes above 30 mL are not helpful and most sources recommend 15 to 20 mL. If the location is difficult to determine through landmarks, ultrasound guidance should be considered. The duration of immobilization after patching is uncertain.

If the platelet count is 70,000 × 10³ per μL (70,000 × 10⁹ per L) or higher, the risk of epidural hematoma is low after a blood patch. Guidelines for neuraxial analgesia should be used if patients are taking antithrombotic agents. Blood patching should be used with caution in patients with signs of systematic infection, such as fever.

Other Procedural Treatments

If headaches are refractory to epidural blood patching or if autologous blood injections are contraindicated, fibrin glue may be an option despite an association with anaphylaxis and aseptic meningitis.

Greater occipital nerve blocks using narrow-gauge needles can reduce headaches, although recurrence is common. Epidural injection of dextran, gelatin, or hydroxyethyl starch does not appear beneficial in postdural puncture headache. Sphenopalatine ganglion blocks, spinal or epidural morphine, and acupuncture have no evidence of benefit.

Patients should be followed until headache resolves, including collaboration with primary care. Patients should be aware of potential long-term complications of postdural puncture headache (Table 1) and that it is not certain whether blood patching reduces these outcomes. Urgent neuroimaging and referral are recommended for a changing headache, new neurologic symptoms, or worsening symptoms after an epidural blood patch.

Editor’s Note: Within my obstetrics experiences, I have diagnosed several postdural puncture headaches after epidural analgesia with delivery. It can be challenging to convince anesthesia providers to perform epidural blood patches after analgesia and caffeine have been ineffective. Yet, timing is important because recurrence is more common when patching is performed less than 48 hours after dural puncture.

—Michael J. Arnold, MD, Assistant Medical Editor

The views expressed are those of the author and do not necessarily reflect the official policy or position of the Naval Undersea Medical Institute, Uniformed Services University of the Health Sciences, U.S. Navy, U.S. Department of Defense, or U.S. government.

Guideline source: Multisociety, International Working Group

Published source: Uppal V, Russell R, Sondekoppam R, et al. Consensus practice guidelines on postdural puncture headache from a multisociety, international working group: a summary report. JAMA Netw Open. 2023;6(8):e2325387.

Available at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808365