For Clinicians
Contents
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.
Background
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
Pathophysiology
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)
Features
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:
Infective
Meningitis
Encephalitis
Sinusitis
Vascular
Migraine
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
Neoplastic
Space occupying lesion
Pseudo tumour cerebri
Pharmacological/Metabolic
Hypoglycaemia
Dehydration
Caffeine withdrawal
Medication side effect (e.g. magnesium, ondansetron)
Other
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
PDPH
Preeclampsia/Eclampsia
Tension headache
Benign intracranial hypertension
Posterior reversible encephalopathy syndrome
Diagnosis
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
Goals:
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)
Mechanism
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
Process
Check for neuraxial contraindications
Sepsis (fever, symptoms/signs of infection, raised WCC/CRP)
Coagulopathy (including recent anticoagulant administration)
Patient refusal
Consent
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
Block
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
Transnasal
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)
Process
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
Block
Prevents pain sensation of that region
Has been used for occipital neuralgia, migraine, cluster headaches
Process
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