# Post-dural-puncture headache

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Common side effect of lumbar puncture or spinal anaesthesia

Medical condition

Post-dural-puncture headache Other names Post-spinal-puncture headache,[1] post-lumbar-puncture headache,[2] spinal headache, epidural headache, low-pressure headache PDPH is a common side effect of spinal anaesthesia (pictured). Specialty Anaesthesiology

**Post-dural-puncture headache** (**PDPH**) is a complication of puncture of the [dura mater](/source/Dura_mater) (one of the membranes around the [brain](/source/Brain) and [spinal cord](/source/Spinal_cord)).[3] The headache is severe and described as "searing and spreading like hot metal", involving the back and front of the head and spreading to the neck and shoulders, sometimes involving [neck stiffness](/source/Neck_stiffness). It is exacerbated by movement and sitting or standing and is relieved to some degree by lying down. Nausea, vomiting, pain in arms and legs, hearing loss, [tinnitus](/source/Tinnitus), [vertigo](/source/Vertigo), [dizziness](/source/Dizziness) and [paraesthesia](/source/Paraesthesia) of the scalp are also common.[3]

PDPH is a common side effect of [lumbar puncture](/source/Lumbar_puncture) and [spinal anesthesia](/source/Spinal_anesthesia). Leakage of [cerebrospinal fluid](/source/Cerebrospinal_fluid) causes reduced fluid pressure in the brain and spinal cord. Onset occurs within two days in 66% of cases and three days in 90%. It occurs so rarely immediately after puncture that other possible causes should be investigated when it does.[3]

Using a pencil-point needle rather than a cutting spinal needle decreases the risk of developing PDPH.[4][1] Smaller needle gauges decrease the odds of PDPH, but make it more challenging to perform the procedure successfully.[3][1] The needle with the lowest PDPH rate and highest succession rate is the 26G pencil-point needle.[5] Its estimated PDPH rate is between 2% and 10%.[1]

## Signs and symptoms

PDPH typically occurs hours to days after puncture and presents with symptoms such as [headache](/source/Headache) (which is mostly bi-frontal or occipital) and [nausea](/source/Nausea) that typically worsen when the patient assumes an upright posture. The headache usually occurs 24–48 hours after puncture but may occur as many as 12 days after.[2] It usually resolves within a few days but has been rarely documented to take much longer.[2]

## Pathophysiology

PDPH is thought to result from a loss of [cerebrospinal fluid](/source/Cerebrospinal_fluid)[3] into the [epidural space](/source/Epidural_space). A decreased [hydrostatic pressure](/source/Hydrostatic_pressure) in the [subarachnoid space](/source/Subarachnoid_space) then leads to traction to the [meninges](/source/Meninges) with associated symptoms.[*[citation needed](https://en.wikipedia.org/wiki/Wikipedia:Citation_needed)*]

## Diagnosis

### Differential diagnosis

Although in very rare cases the headache may present immediately after a puncture, this is almost always due to another cause such as increased intracranial pressure and requires immediate attention.[2]

## Prevention

Using a pencil point rather than a cutting spinal needle decreases the risk.[6] The size of the pencil point needle does not appear to make a difference, while smaller cutting needles have a low risk compared to larger ones.[6] Modern, atraumatic needles such as the Sprotte or Whitacre spinal needle leave a smaller perforation and reduce the risk for PDPH.[1] However, the evidence that atraumatic needles reduce the risk of post-dural puncture headache (PDPH) without increasing adverse events such as paraesthesia or backache is moderate-quality and further research should be done.[7]

[Morphine](/source/Morphine), [cosyntropin](/source/Cosyntropin), and [aminophylline](/source/Aminophylline) appear effective in reducing post dural puncture headaches.[8] Evidence does not support the use of bed rest or intravenous fluids to prevent PDPH.[9]

## Treatment

Some people require no other treatment than [pain medications](/source/Analgesic) and [bed rest](/source/Bed_rest). A 2015 review found tentative evidence to support the use of [caffeine](/source/Caffeine).[10] Vigorous hydration is routinely encouraged in postpartum patients.[11]

Pharmacological treatments as; gabapentin, pregabalin,[12] neostigmine/atropine,[13] methylxanthines, and [triptans](/source/Triptan).[14] Minimally invasive procedures as; bilateral greater occipital nerve block [15] or sphenopalatine ganglion block.[16]

Persistent and severe PDPH may require an [epidural blood patch](/source/Epidural_blood_patch) (EBP). A small amount of the person's [blood](/source/Blood) is injected into the epidural space near the site of the original puncture; the resulting [blood clot](/source/Blood_clot) then "patches" the meningeal leak.

EBP is effective,[17] and further intervention is rarely necessary. 25–35% of patients suffer from transient back pain after EBP.[18] More rare complications of EBP include misplacement of blood leading to spinal [subdural hematoma](/source/Subdural_hematoma)[19] or intrathecal injection and arachnoiditis,[20] infection with [subdural abscess](/source/Subdural_abscess),[21] [facial nerve paralysis](/source/Facial_nerve_paralysis),[22] [spastic](/source/Spasticity) [paraparesis](/source/Paraparesis) and [cauda equina syndrome](/source/Cauda_equina_syndrome).[23]

## Epidemiology

Estimates for the overall incidence of PDPH vary between 0.1% and 36%.[1] It is more common in younger patients (especially in the 18–30 age group), women (especially those who are pregnant), and those with a low [body mass index](/source/Body_mass_index) (BMI). The low prevalence in elderly patients may be due to a less stretchable dura mater.[2] It is also more common with the use of larger diameter needles. A 2006 review reported an incidence of:

- 12% if a needle between 0.4128 mm (0.01625 in) and 0.5652 mm (0.02225 in) is used;

- 40% if a needle between 0.7176 mm (0.02825 in) and 0.9081 mm (0.03575 in) is used; and

- 70% if a needle between 1.067 mm (0.0420 in) and 1.651 mm (0.0650 in) is used.[2]

On the [Birmingham gauge](/source/Birmingham_gauge), these correspond to the values 27–24G, 22–20G and 19–16G.[2]

PDPH is roughly twice as common in lumbar puncture than spinal anaesthesia, almost certainly due to the atraumatic needles used in spinal anaesthesia.[24]

## References

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## External links

Classification D ICD-10: G44.820, G97.0 ICD-9-CM: 349.0 MeSH: D051299

v t e Headache Primary ICHD 1 Migraine Familial hemiplegic Retinal migraine ICHD 2 Tension Mixed tension migraine ICHD 3 Cluster Chronic paroxysmal hemicrania SUNCT ICHD 4 Hemicrania continua Thunderclap headache Sexual headache New daily persistent headache Hypnic headache Secondary ICHD 5 Migralepsy ICHD 7 Ictal headache Post-dural-puncture headache ICHD 8 Hangover Medication overuse headache ICHD 13 Trigeminal neuralgia Occipital neuralgia External compression headache Cold-stimulus headache Optic neuritis Postherpetic neuralgia Tolosa–Hunt syndrome Other Eye strain Orthostatic Vascular

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Adapted from the Wikipedia article [Post-dural-puncture headache](https://en.wikipedia.org/wiki/Post-dural-puncture_headache) by Wikipedia contributors ([contributor history](https://en.wikipedia.org/wiki/Post-dural-puncture_headache?action=history)). Available under [Creative Commons Attribution-ShareAlike 4.0 International](https://creativecommons.org/licenses/by-sa/4.0/). Changes may have been made.