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.