{{short description|Common side effect of lumbar puncture or spinal anaesthesia}} {{Infobox medical condition (new) | name = Post-dural-puncture headache | synonyms = Post-spinal-puncture headache,<ref name=Jab2013 /> post-lumbar-puncture headache,<ref name=":0" /> spinal headache, epidural headache, low-pressure headache | image = Spinal anaesthesia.jpg | caption = PDPH is a common side effect of [[spinal anaesthesia]] ''(pictured)''. | pronounce = | field = anaesthesiology | symptoms = | complications = | onset = | duration = | types = | causes = | risks = | diagnosis = | differential = | prevention = | treatment = | medication = | prognosis = | frequency = | deaths = | alt = }} '''Post-dural-puncture headache''' ('''PDPH''') is a complication of puncture of the [[dura mater]] (one of the membranes around the [[brain]] and [[spinal cord]]).<ref name="pmid14570796">{{cite journal | vauthors = Turnbull DK, Shepherd DB | title = Post-dural puncture headache: pathogenesis, prevention and treatment | journal = British Journal of Anaesthesia | volume = 91 | issue = 5 | pages = 718–29 | date = November 2003 | pmid = 14570796 | doi = 10.1093/bja/aeg231 | doi-access = free }}</ref> 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]]. 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]], [[vertigo]], [[dizziness]] and [[paraesthesia]] of the scalp are also common.<ref name="pmid14570796" />
<!-- Cause and diagnosis --> PDPH is a common side effect of [[lumbar puncture]] and [[spinal anesthesia]]. Leakage of [[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.<ref name="pmid14570796"/>
<!-- Prevention, treatment and epidemiology --> Using a pencil-point needle rather than a cutting spinal needle decreases the risk of developing PDPH.<ref>{{Cite journal |last1=Arevalo-Rodriguez |first1=Ingrid |last2=Muñoz |first2=Luis |last3=Godoy-Casasbuenas |first3=Natalia |last4=Ciapponi |first4=Agustín |last5=Arevalo |first5=Jimmy J |last6=Boogaard |first6=Sabine |last7=Roqué i Figuls |first7=Marta |date=2017-04-07 |title=Needle gauge and tip designs for preventing post-dural puncture headache (PDPH) |journal=The Cochrane Database of Systematic Reviews |volume=2017 |issue=4 |article-number=CD010807 |doi=10.1002/14651858.CD010807.pub2 |issn=1469-493X |pmc=6478120 |pmid=28388808}}</ref><ref name="Jab2013" /> Smaller needle gauges decrease the odds of PDPH, but make it more challenging to perform the procedure successfully.<ref name="pmid14570796" /><ref name="Jab2013" /> The needle with the lowest PDPH rate and highest succession rate is the 26G pencil-point needle.<ref>{{Cite journal |last1=Maranhao |first1=B. |last2=Liu |first2=M. |last3=Palanisamy |first3=A. |last4=Monks |first4=D. T. |last5=Singh |first5=P. M. |date=August 2021 |title=The association between post-dural puncture headache and needle type during spinal anaesthesia: a systematic review and network meta-analysis |journal=Anaesthesia |volume=76 |issue=8 |pages=1098–1110 |doi=10.1111/anae.15320 |issn=1365-2044 |pmid=33332606}}</ref> Its estimated PDPH rate is between 2% and 10%.<ref name=Jab2013>{{cite journal | vauthors = Jabbari A, Alijanpour E, Mir M, Bani Hashem N, Rabiea SM, Rupani MA | title = Post spinal puncture headache, an old problem and new concepts: review of articles about predisposing factors | journal = Caspian Journal of Internal Medicine | volume = 4 | issue = 1 | pages = 595–602 | date = 2013 | pmid = 24009943 | pmc = 3762227 }}</ref>
==Signs and symptoms== PDPH typically occurs hours to days after puncture and presents with symptoms such as [[headache]] (which is mostly bi-frontal or occipital) and [[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.<ref name=":0" /> It usually resolves within a few days but has been rarely documented to take much longer.<ref name=":0" />
==Pathophysiology== PDPH is thought to result from a loss of [[cerebrospinal fluid]]<ref name="pmid14570796"/> into the [[epidural space]]. A decreased [[hydrostatic pressure]] in the [[subarachnoid space]] then leads to traction to the [[meninges]] with associated symptoms.{{citation needed|date=August 2021}}
== 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.<ref name=":0" />
==Prevention== Using a pencil point rather than a cutting spinal needle decreases the risk.<ref name="Zor2018">{{cite journal |vauthors=Zorrilla-Vaca A, Mathur V, Wu CL, Grant MC |date=July 2018 |title=The Impact of Spinal Needle Selection on Postdural Puncture Headache: A Meta-Analysis and Metaregression of Randomized Studies |journal=Regional Anesthesia and Pain Medicine |volume=43 |issue=5 |pages=502–508 |doi=10.1097/AAP.0000000000000775 |pmid=29659437 |s2cid=4956569}}</ref> 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.<ref name="Zor2018" /> Modern, atraumatic needles such as the Sprotte or Whitacre spinal needle leave a smaller perforation and reduce the risk for PDPH.<ref name=Jab2013 /> 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.<ref>{{cite journal | vauthors = Arevalo-Rodriguez I, Muñoz L, Godoy-Casasbuenas N, Ciapponi A, Arevalo JJ, Boogaard S, Roqué I, Figuls M | title = Needle gauge and tip designs for preventing post-dural puncture headache (PDPH) | journal = The Cochrane Database of Systematic Reviews | volume = 4 | article-number = CD010807 | date = April 2017 | issue = 12 | pmid = 28388808 | pmc = 6478120 | doi = 10.1002/14651858.CD010807.pub2 | collaboration = Cochrane Anaesthesia Group }}</ref>
[[Morphine]], [[cosyntropin]], and [[aminophylline]] appear effective in reducing post dural puncture headaches.<ref>{{cite journal | vauthors = Basurto Ona X, Uriona Tuma SM, Martínez García L, Solà I, Bonfill Cosp X | title = Drug therapy for preventing post-dural puncture headache | journal = The Cochrane Database of Systematic Reviews | issue = 2 | article-number = CD001792 | date = February 2013 | volume = 2016 | pmid = 23450533 | doi = 10.1002/14651858.cd001792.pub3 | pmc = 8406520 }}</ref> Evidence does not support the use of bed rest or intravenous fluids to prevent PDPH.<ref>{{cite journal | vauthors = Arevalo-Rodriguez I, Ciapponi A, Roqué i Figuls M, Muñoz L, Bonfill Cosp X | title = Posture and fluids for preventing post-dural puncture headache | journal = The Cochrane Database of Systematic Reviews | volume = 3 | article-number = CD009199 | date = March 2016 | issue = 4 | pmid = 26950232 | pmc = 6682345 | doi = 10.1002/14651858.CD009199.pub3 }}</ref>
==Treatment== Some people require no other treatment than [[analgesic|pain medication]]s and [[bed rest]]. A 2015 review found tentative evidence to support the use of [[caffeine]].<ref>{{cite journal | vauthors = Basurto Ona X, Osorio D, Bonfill Cosp X | title = Drug therapy for treating post-dural puncture headache | journal = The Cochrane Database of Systematic Reviews | volume = 7 | issue = 7 | article-number = CD007887 | date = July 2015 | pmid = 26176166 | pmc = 6457875 | doi = 10.1002/14651858.CD007887.pub3 }}</ref> Vigorous hydration is routinely encouraged in postpartum patients.<ref>{{Cite journal |last1=Harrington |first1=Brian E. |last2=Schmitt |first2=Andrew M. |date=September 2009 |title=Meningeal (postdural) puncture headache, unintentional dural puncture, and the epidural blood patch: a national survey of United States practice |journal=Regional Anesthesia and Pain Medicine |volume=34 |issue=5 |pages=430–437 |doi=10.1097/AAP.0b013e3181b493e9 |issn=1532-8651 |pmid=19749586|s2cid=39028435 }}</ref>
Pharmacological treatments as; gabapentin, pregabalin,<ref>{{Cite journal|last1=Mahoori|first1=Alireza|last2=Noroozinia|first2=Heydar|last3=Hasani|first3=Ebrahim|last4=Saghaleini|first4=Hadi|date=2014|title=Comparing the effect of pregabalin, gabapentin, and acetaminophen on post-dural puncture headache|journal=Saudi Journal of Anaesthesia|language=en|volume=8|issue=3|pages=374–377|doi=10.4103/1658-354X.136436|pmid=25191190|issn=1658-354X|pmc=4141388 |doi-access=free }}</ref> neostigmine/atropine,<ref>{{Cite journal|last1=Abdelaal Ahmed Mahmoud|first1=Ahmed|last2=Mansour|first2=Amr Zaki|last3=Yassin|first3=Hany Mahmoud|last4=Hussein|first4=Hazem Abdelwahab|last5=Kamal|first5=Ahmed Moustafa|last6=Elayashy|first6=Mohamed|last7=Elemady|first7=Mohamed Farid|last8=Elkady|first8=Hany W.|last9=Mahmoud|first9=Hatem Elmoutaz|last10=Cusack|first10=Barbara|last11=Hosny|first11=Hisham|date=2018-12-01|title=Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache: A Randomized Controlled Trial|journal=Anesthesia & Analgesia|language=en|volume=127|issue=6|pages=1434–1439|doi=10.1213/ANE.0000000000003734|pmid=30169405|s2cid=52142441|issn=0003-2999}}</ref> methylxanthines, and [[triptan]]s.<ref>{{Cite journal|last1=Shaat|first1=Ahmed Mohamed|last2=Abdalgaleil|first2=Mohamed Mahmoud|date=2021-01-01|title=Is theophylline more effective than sumatriptan in the treatment of post-dural puncture headache? A randomized clinical trial|journal=Egyptian Journal of Anaesthesia|language=en|volume=37|issue=1|pages=310–316|doi=10.1080/11101849.2021.1949195|issn=1110-1849|doi-access=free}}</ref> Minimally invasive procedures as; bilateral greater occipital nerve block <ref>{{Cite journal|last1=Mostafa Mohamed Stohy|first1=El-Sayed|last2=Mohamed Mohamed El-Sayed|first2=Mostafa|last3=Saeed Mohamed Bastawesy|first3=Mohamed|title=The Effectiveness of Bilateral Greater Occipital Nerve Block by Ultrasound for Treatment of Post-Dural Puncture Headache in Comparison with Other Conventional Treatment|date=2019-10-01|journal=Al-Azhar Medical Journal|volume=48|issue=4|pages=479–488|doi=10.21608/amj.2019.64954|issn=1110-0400|doi-access=free}}</ref> or sphenopalatine ganglion block.<ref>{{Cite journal|last1=Jespersen|first1=Mads S.|last2=Jaeger|first2=Pia|last3=Ægidius|first3=Karen L.|last4=Fabritius|first4=Maria L.|last5=Duch|first5=Patricia|last6=Rye|first6=Ida|last7=Afshari|first7=Arash|last8=Meyhoff|first8=Christian S.|date=2020-04-15|title=Sphenopalatine ganglion block for the treatment of postdural puncture headache: a randomised, blinded, clinical trial|journal=British Journal of Anaesthesia|language=en|volume=124|issue=6|pages=739–747|doi=10.1016/j.bja.2020.02.025|pmid=32303377|doi-access=free}}</ref>
Persistent and severe PDPH may require an [[epidural blood patch]] (EBP). A small amount of the person's [[blood]] is injected into the epidural space near the site of the original puncture; the resulting [[blood clot]] then "patches" the meningeal leak.
EBP is effective,<ref name="pmid11506102">{{cite journal | vauthors = Safa-Tisseront V, Thormann F, Malassiné P, Henry M, Riou B, Coriat P, Seebacher J | title = Effectiveness of epidural blood patch in the management of post-dural puncture headache | journal = Anesthesiology | volume = 95 | issue = 2 | pages = 334–9 | date = August 2001 | pmid = 11506102 | doi = 10.1097/00000542-200108000-00012 | s2cid = 569494 | doi-access = free }}</ref> and further intervention is rarely necessary. 25–35% of patients suffer from transient back pain after EBP.<ref>{{Cite journal |last1=Desai |first1=Mehul J. |last2=Dave |first2=Ankur P. |last3=Martin |first3=Megan B. |date=May 2010 |title=Delayed radicular pain following two large volume epidural blood patches for post-lumbar puncture headache: a case report |journal=Pain Physician |volume=13 |issue=3 |pages=257–262 |doi=10.36076/ppj.2010/13/257 |issn=2150-1149 |pmid=20495590|doi-access=free }}</ref> More rare complications of EBP include misplacement of blood leading to spinal [[subdural hematoma]]<ref>{{Cite journal |last1=Tekkök |first1=Ismail H. |last2=Carter |first2=David A. |last3=Brinker |first3=Ray |date=1996-03-01 |title=Spinal subdural haematoma as a complication of immediate epidural blood patch |journal=Canadian Journal of Anaesthesia |language=en |volume=43 |issue=3 |pages=306–309 |doi=10.1007/BF03011749 |pmid=8829870 |issn=1496-8975|doi-access=free }}</ref> or intrathecal injection and arachnoiditis,<ref>{{Cite journal |last1=Kalina |first1=Peter |last2=Craigo |first2=Paula |last3=Weingarten |first3=Toby |date=August 2004 |title=Intrathecal injection of epidural blood patch: a case report and review of the literature |journal=Emergency Radiology |volume=11 |issue=1 |pages=56–59 |doi=10.1007/s10140-004-0365-0 |issn=1070-3004 |pmid=15278703|s2cid=436062 }}</ref> infection with [[subdural abscess]],<ref>{{Cite journal |last1=Collis |first1=R. E. |last2=Harries |first2=S. E. |date=July 2005 |title=A subdural abscess and infected blood patch complicating regional analgesia for labour |journal=International Journal of Obstetric Anesthesia |volume=14 |issue=3 |pages=246–251 |doi=10.1016/j.ijoa.2005.03.002 |issn=0959-289X |pmid=15935637}}</ref> [[facial nerve paralysis]],<ref>{{Cite journal |last1=Shahien |first1=Radi |last2=Bowirrat |first2=Abdalla |date=2011-02-02 |title=Facial nerve paralysis and partial brachial plexopathy after epidural blood patch: a case report and review of the literature |journal=Journal of Pain Research |volume=4 |pages=39–45 |doi=10.2147/JPR.S15314 |issn=1178-7090 |pmc=3048582 |pmid=21386953 |doi-access=free }}</ref> [[Spasticity|spastic]] [[paraparesis]] and [[cauda equina syndrome]].<ref>{{Cite journal |last1=Mehta |first1=Sonya P. |last2=Keogh |first2=Bart P. |last3=Lam |first3=Arthur M. |date=January 2014 |title=An epidural blood patch causing acute neurologic dysfunction necessitating a decompressive laminectomy |journal=Regional Anesthesia and Pain Medicine |volume=39 |issue=1 |pages=78–80 |doi=10.1097/AAP.0000000000000025 |issn=1532-8651 |pmid=24310044|s2cid=21920366 }}</ref>
== Epidemiology == Estimates for the overall incidence of PDPH vary between 0.1% and 36%.<ref name=Jab2013/> 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]] (BMI). The low prevalence in elderly patients may be due to a less stretchable dura mater.<ref name=":0" /> It is also more common with the use of larger diameter needles. A 2006 review reported an incidence of: * 12% if a needle between {{Convert|0.4128|mm|in|abbr=on}} and {{Convert|0.5652|mm|in|abbr=on}} is used; * 40% if a needle between {{Convert|0.7176|mm|in|abbr=on}} and {{Convert|0.9081|mm|in|abbr=on}} is used; and * 70% if a needle between {{Convert|1.067|mm|in|abbr=on}} and {{Convert|1.651|mm|in|abbr=on}} is used.<ref name=":0">{{cite journal | vauthors = Ahmed SV, Jayawarna C, Jude E | title = Post lumbar puncture headache: diagnosis and management | journal = Postgraduate Medical Journal | volume = 82 | issue = 973 | pages = 713–6 | date = November 2006 | pmid = 17099089 | pmc = 2660496 | doi = 10.1136/pgmj.2006.044792 }}</ref>
On the [[Birmingham gauge]], these correspond to the values 27–24G, 22–20G and 19–16G.<ref name=":0" />
PDPH is roughly twice as common in lumbar puncture than spinal anaesthesia, almost certainly due to the atraumatic needles used in spinal anaesthesia.<ref>{{cite journal | vauthors = Alstadhaug KB, Odeh F, Baloch FK, Berg DH, Salvesen R | title = Post-lumbar puncture headache | journal = Tidsskrift for den Norske Laegeforening | volume = 132 | issue = 7 | pages = 818–21 | date = April 2012 | pmid = 22511093 | doi = 10.4045/tidsskr.11.0832 | doi-access = free }}</ref>
== References == {{Reflist|30em}}
== External links == {{Medical resources | DiseasesDB = | ICD10 = G44.820, G97.0 | ICD9 = {{ICD9|349.0}} | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj = | eMedicineTopic = | MeshID = D051299 }} {{Headache}}
[[Category:Headaches]]