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For Clinicians


Image by National Cancer Institute

This page is designed as a guide for clinicians when caring for someone with a post dural puncture headache (PDPH).  All attempts have been made to keep the information as up to date and evidenced based as possible but it can not replace individualised patient care and decision making.

Click on the links below or scroll through the page for more information.




Impact of PDPH

Differential Diagnosis


Follow up

Prevention of PDPH

Treatment of PDPH

Epidural Blood Patch

Nerve Blocks


A PDPH is a “headache occurring within 5 days of a lumbar puncture, caused by cerebrospinal fluid (CSF) leakage through the dural puncture. It is usually accompanied by neck stiffness and/or subjective hearing symptoms. It remits spontaneously within 2 weeks, or after sealing of the leak with autologous epidural lumbar patch.” (International Headache Society)

90% of headaches will occur within 3 days of dural puncture, 66% within the first 48 hours.

Risk is 1-80% depending on:

  • Needle gauge/type

    • Highest risk =​

      • Tuohy needle​ (i.e. an accidental dural puncture)

      • Cutting (e.g. Quincke) and larger calibre spinal needles

  • Needle orientation (when using a cutting needle)​​

    • Higher risk with cutting bevel perpendicular to long axis of spine​

  • Operator skill​

    • Increased risk with multiple attempts and low case volume specialists and during "novice" training stage​

  • Patient risk factors e.g.  younger age, female, obstetric patient, history of PDPH (4x more likely to get repeat PDPH), history of chronic headaches, depth to epidural space


The cause is a needle puncturing the dura.

This can be intentional:

  • Diagnostic lumbar puncture (PDPH risk 36%)

  • Spinal anaesthesia (PDPH risk ~ 1%)

Or unintentional (during epidural insertion):

  • Risk of unintentional dural puncture ~ 1%

  • PDPH risk if dural puncture occurs = up to 50-80%

The dural puncture causes a CSF leak from the subarachnoid space with decreased CSF volume and pressure.  This may cause a headache because of: 

  • Tension on cranial nerves and vessels – exacerbated by upright position

  • Veno- and vasodilation due to CSF hypotension (Monro-Kellie doctrine)


  • Known dural puncture (either intentional (spinal anaesthetic) or unintentional (epidural)); but up to 1/3 of PDPH cases do not have a recognised accidental dural puncture

  • Headache

    • Positional

      • Worsens within 15 minutes of sitting or standing

      • Improves within 15 minutes of lying down

    • Frontal, occipital or posterior (back of neck)

  • Associated symptoms (up to 70% of patients)

    • Neck stiffness and neck/shoulder/intrascapular pain

    • Tinnitus

    • Hearing loss (?tension on CNVIII)

    • Photophobia

    • Nausea

    • Dizziness/vertigo

  • Usually starts within 48h of neuraxial procedure, usually resolves within 2 weeks if epidural or 2-3 days if spinal anaesthetic

Impact of PDPH

Short term significant disability

  • Restricted activity (with potential for VTE risk)

  • Difficulties caring for newborn

  • Prolonged hospital stay

Longer term risks

  • Chronic headache

    • Relative risk around 2 compared to postpartum people without PDPH

      • 56% of people had significant headaches at 6/12 postpartum

  • Chronic backache/neckache

  • Postpartum depression and post-traumatic stress disorder

  • Decreased breastfeeding rates

(unclear whether these are reduced by treatment with epidural blood patch)

Rare risks

  • Cranial nerve palsy

  • Subdural haematoma (0.5%, ?due to traction/tearing of bridging veins)

  • Cerebral venous thrombosis

  • Bacterial meningitis

Differential Diagnosis

40% of people will have headache postnatally, ~ 50-75% of these are benign primary headaches (e.g. migraine, tension headache).

The differential diagnosis for post-partum headache includes:




Cerebral arterial or venous thrombosis or cortical vein thrombosis
Hypertensive encephalopathy or bleeding
Subdural or subarachnoid haemorrhage
Ruptured aneurysm or AVM
Ischaemic stroke
Temporal arteritis


Space occupying lesion
Pseudo tumour cerebri


Caffeine withdrawal
Medication side effect (e.g. magnesium, ondansetron)


Lactation headache
Nonspecific headache (e.g. stress)
Pituitary apoplexy
Pneumocephalus – can occur if loss of resistance to air is used rather than saline during epidural insertion
Tension headache
Benign intracranial hypertension
Posterior reversible encephalopathy syndrome


History and examination

  • Looking for features as above

  • Inspect insertion site looking for inflammation and tenderness

  • Check vital signs (may suggest alternative diagnosis e.g. if fever or hypertension present)

  • Review notes from neuraxial insertion (remembering that PDPH can occur following unrecognised dural puncture)

Consider other causes

  • See list above

  • May need:​
    • Radiological investigations

    • Review by other specialties e.g. neurology, neurosurgery, obstetrics

    • Blood tests

Red flags (requiring urgent imaging/neurology input):

  • Change in severity or nature of headache

  • Altered level of consciousness

  • Seizures

  • Focal neurological signs

CT/MRI findings consistent with PDPH:

  • Small ventricles

  • Downward displacement of brain

  • Engorged cerebral venous sinuses

  • Subdural fluid collections

  • Pituitary enlargement

  • Diffuse meningeal enhancement

Follow up

  • Identify patients who have had a difficult neuraxial block (spinal or epidural) e.g. multiple attempts, known or suspected accidental dural puncture

  • Follow them up (including if discharged)

  • Identify PDPH

  • Offer treatment including EBP

  • Monitoring for long-term PDPH side effects

  • Communicate with primary care providers (Lead Maternity Care midwife/GP)

Prevention of PDPH

Neuraxial procedural factors

  • Needle type/gauge

    • Spinal – 26G atraumatic (pencil point e.g. Whitacre and Sprotte) spinal needle offers best compromise for lowering incidence of PDPH without significantly increasing risk of procedural difficulty

  • Skilled operator and assistant

    • Balance between training requirements and patient care

    • Consider choosing experienced/high volume practitioner if risk factors present particularly previous PDPH

  • For epidural insertion

    • Careful explanation and engagement with patient to improve compliance to reduce risk of unintended dural puncture

  • Possible benefit of using ultrasound for neuraxial placement

Management of unintended dural puncture

  • Mixed evidence RE: benefit of threading catheter intrathecally

    • Possibly:

      • Obstructs hole and reduces CSF efflux

      • Causes inflammatory response which promotes healing

    • Need to balance with risk of epidural doses being given by intrathecal catheter with potential for high/total spinal

    • Some references suggest leaving in for some time post-delivery but significant concerns about people being on postnatal ward with intrathecal catheter (inadvertent injection of unintended medications) and risk of infection

  • Vs. removing needle and reattempting epidural catheter at another level

    • Need to take care with doses (LA can move intrathecally through hole in dura)

Prophylactic Epidural Blood Patch (EBP)

  • See below for more details about EBP

  • Unclear benefit of prophylactic EBP

    • Possibly decrease severity and duration of headache but not incidence

    • Improved PDPH compared to no treatment, conservative treatment and epidural saline but no benefit when compared to sham procedure

  • Not widely recommended

Treatment of PDPH

Much of the evidence is poor quality

Headaches will resolve over time, usually within a week


Decrease duration of headache

Reduce headache severity

Improve ability to perform acitivites of daily living

Reduce length of stay in hospital

Conservative Treatment

Often conservative treatment offered initially especially if PDPH after spinal anaesthetic (and therefore expected to resolve in 2-3 days) and mild headache.

Conservative treatment options include:

  • Bed rest

    • No evidence that it treats/prevents PDPH but often necessary due to headache with mobilising

    • Need to ensure appropriate VTE prophylaxis and assistance provided to care for newborn

  • Abdominal binders – not widely recommended

  • Analgesics

    • Paracetamol

    • NSAIDs

    • Opioids (avoid prolonged treatment)

  • Hydration

    • May help increase CSF production

    • No evidence for over-hydration but sensible to avoid dehydration and it’s potential contribution to headache

  • Caffeine beverages

    • Caffeine causes cerebral vasoconstriction

    • Inconclusive data with dose range 75-500mg orally and IV

    • If usually a caffeine consumer, probably worthwhile continuing to avoid superimposed caffeine withdrawal headache

  • Antiemetics

Medical treatments

  • Limited and small studies

  • No reduction in EBP requirement but some evidence of reduced pain scores with:

    • IV Caffeine​

    • Gabapentin (care with breastfeeding)​

    • Hydrocortisone​​

    • Theophylline​

    • Dexmedetomidine

  • Insufficient evidence – sumatriptan, ACTH, pregabalin, acupuncture

Procedural Treatments

There are two procedural treatments that can be used to treat a PDPH:

  • Epidural Blood Patch (EBP)

  • Nerve Blocks

    • Sphenopalatine Nerve Block

    • Greater Occipital Nerve Block

These are described below in more detail

ACC Treatment Injury

If you are in New Zealand, please consider completing an ACC Treatment Injury form for people who are experiencing a PDPH.  You will need to complete both an ACC45 form plus the Treatment Injury Form (ACC2152).  The code is L384 (Obstetric spinal and epidural anaesthesia-induced headache). 

Although completing the form takes time, it may provide benefit to the patient if they have longstanding symptoms, a significant complication, or need additional assistance during their recovery.

Epidural Blood Patch (EBP)

First done in 1960s after it was noted that people with bloody spinal taps at LP were less likely to develop PDPH

“Gold standard” treatment for PDPH

  • 50-80% have improvement or resolution of headache (more likely to succeed if done for PDPH from spinal needle)

  • Often provides immediate symptom relief

  • Treatment of choice with cranial nerve symptoms, for debilitating headache, and for headache not responding to conservative management

  • May be more effective if 48h+ since dural puncture (but if significant headache then likely better to proceed ASAP even if < 48h)


Not entirely clear, postulated mechanisms include:

  • Tamponade effect of blood in epidural space with increased intracranial pressure and relief from headache

  • Formation of clot seals puncture site and blocks further leakage of CSF

Risks of EBP

  • Difficulty finding epidural space

  • Patient discomfort – during procedure, and back pain afterwards

  • Inadvertant dural puncture

  • Infection

  • Neurological complications


  • Check for neuraxial contraindications

    • Sepsis (fever, symptoms/signs of infection, raised WCC/CRP)

    • Coagulopathy (including recent anticoagulant administration)

    • Patient refusal

  • Consent

    • Full informed consent process

    • EBP may be declined by Jehovah’s Witness patients (case reports available where a closed system was used - link here and here

  • Appropriate location

    • Hospital dependent – may be theatre, PACU/recovery, treatment room

  • 2-3 people

    • Experienced anaesthetist (to do epidural/guide procedure)

    • Another staff member competent to take blood

    • +/- Assistant to help with positioning, support, equipment etc.

  • Practical tips

    • Ask patient to go to the toilet before starting

    • Consider feeding newborn and having help available to care for newborn during procedure and while resting afterwards

  • Standard monitoring + IV access (this could be done aseptically and used to obtain blood for EBP)

  • Strict asepsis for both procedural staff members

  • Lateral or sitting (depending on what patient can manage)

  • Epidural performed (usually by more senior anaesthetic doctor)

    • At same interspace as original dural puncture or one space below

    • Once epidural space located then 20-30mL of patient’s blood drawn (by other staff member)

    • This is passed to the clinician performing the epidural and the blood is injected slowly in to epidural space until headache resolves or patient reports discomfort in back.

      • Optimal volume not known - around 20mL probably best

      • Stop if back pain occurs, wait until pain resolves, then can try again to inject more if < 15mL given, if back pain recurs, stop and don’t give more

  • Lie flat for 1-2 hours and avoid heavy lifting for first 24-48h – not evidence based but common practice

  • Give information on discharge about concerning symptoms and when to seek help/who they should contact; taper other analgesia (to avoid withdrawal headache)

Repeat EBPs

  • Up to 20-30% of patients may need repeat EBP

  • Consider 2nd EBP if strong suspicion of PDPH and partial or brief relief of headache with 1st EBP

  • If no relief with 1st EBP, consult/image as below

  • Prior to proceeding with 3rd EBP, strongly consider neuro-imaging (CT/MRI) +/- input from neurology/neurosurgery

Alternative solutions for epidural patch (instead of blood)

  • No evidence to support use e.g. Dextran, Gelatin, Hetastarch, Fibrin Glue

  • Epidural normal saline infusion – symptomatic improvement but symptoms recur when stopped

  • Epidural morphine – case studies supporting use, no RCTs

Nerve Blocks


Sphenopalatine Nerve Block

Sphenopalatine ganglion:
- Located in pterygopalatine fossa
- Sympathetic, parasympathetic, and somatosensory components


  • Has been used for migraine, trigeminal neuralgia, cluster headaches, facial pain

  • Possible mechanism

    • Blockade of ganglion -> reduced parasympathetic flow to cerebral vessels -> reduced cerebral vasodilatation

  • Can be done transnasally or transcutaneously


  • Non-invasive, low-risk, performed at bedside

  • Similar location to COVID PCR swab

  • Insufficient data to recommend for PDPH but may be helpful where EBP contraindicated (e.g. anti-coagulant use, patient declining EBP)

  • May provide temporary relief (~6-18 hours)


  • Lignocaine +/- dexamethasone (possibly may help to prolong effect)

  • Make up 2 x 3mL syringes with: 2mL 2% lignocaine + 4mg dexamethasone (3mL total, 2 syringes – one for each nostril)

  • Additional 2% lignocaine soaked cotton tipped swabs

  • Patient supine with shoulders slightly elevated to flex the neck and extend the head

  • Long cotton-tipped applicators saturated with 2% lignocaine inserted in to each naris in to posterior nasopharynx and left for 10 minutes

  • Then 3mL of above solution injected in to sphenopalatine area through each nostril (with blunt tipped device)

  • Alternatively, just swabs soaked in 2% lignocaine can be used

Adverse effects

  • Nausea

  • Bitter taste

  • Discomfort during insertion

  • Nasal/throat pain


Greater occipital nerve block

Great occipital nerve:
- Sensory fibres from C2 and C3
- Innervates medial posterior scalp to anterior side of vertex


  • Prevents pain sensation of that region

  • Has been used for occipital neuralgia, migraine, cluster headaches


  • Lignocaine +/- dexamethasone (possibly may help to prolong effect)

  • E.g. 2mL 2% lignocaine + 4mg dexamethasone (= 3mL total) on each side

  • Patient in prone position

  • Back of head cleaned with antiseptic

  • Landmarks located – medial third of line drawn from occipital protuberance to mastoid process

  • Skin infiltrated with 1-2mL of 2% lignocaine

  • Then block with 3mL as above for each side

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