If you are looking at this website, it is probably because you are experiencing a headache after giving birth.
We hope that this website helps you understand why you have a headache and the treatment options available to manage it.
We have done our absolute best to ensure that this information is accurate. However, it can not replace individualised care and advice provided by the health care professionals looking after you.
A post dural puncture headache (PDPH) is a type of headache that can occur after an epidural or spinal injection.
To understand why the headache occurs we first need to explain what happens during these injections. We will then cover why the headache occurs, what it feels like, and what treatment options may be offered to you to help manage the pain or to try and make the headache go away.
Click on the links below or scroll through this page to find out more.
Epidural and spinal injections
An epidural is usually performed in labour to provide pain relief.
A needle is inserted and used as a guide to thread a plastic tube (or catheter) in to a space in the back (the epidural space). The epidural space is shown in the picture below. It is just before the dura which is one of the layers that lines the spinal cord and brain.
Medicine is given through this plastic tube to relieve pain for the person in labour. Extra medicine can also be given if a caesarean section or other procedure is required.
The needle used for an epidural is a different size and shape than that used for a spinal injection.
A spinal injection is most often performed in the operating theatre for a caesarean section or other procedures required around the time of childbirth.
A very fine needle is inserted through the dura and a cobweb-like layer that is stuck to it (the arachnoid). The needle enters the space containing the clear fluid (CSF or cerebrospinal fluid) that surrounds the brain and spinal cord. This is the same location as a needle enters for a "spinal tap" or lumbar puncture.
Once the needle is in the right place (see the picture below) medicine is injected to numb the areas required for the operation or procedure.
What is a dural puncture?
When you have a spinal or epidural injection it is performed by an anaesthetic doctor. These doctors have completed a medical degree and are training in anaesthesia (an anaesthetic registrar) or have completed their training (an anaesthetic consultant or specialist). They take great care to perform the procedure as carefully as possible.
Both spinal and epidural injections are usually performed by "feel". This means that the doctor finds the correct location to perform the injection by feeling the bones of your back and pelvis. They then find the right layer for the needle by feeling the needle move through your back and by using special techniques to try and make sure the needle is in the correct place. This is similar to when you have a blood test taken - the person taking it will feel your arm to find the vein and will then use the feel of the needle and the blood appearing in the tube to make sure they are in the right place.
Most of the time these techniques work, just like most of the time the person taking a blood test is successful! However, sometimes the needle can end up in the wrong location.
If you have an epidural injection and the needle goes too far it can go through the dura (remember, an epidural needle is aiming to end up just before the dura). This may occur when the person having the epidural moves suddenly, their anatomy is different to usual, or because of a technical issue. This is called an accidental dural puncture - the epidural needle has gone through the dura by accident. The anaesthetist doing the epidural will often know that a dural puncture has occurred and will explain this to you at the time.
However, when an anaesthetic doctor is doing a spinal injection they are actually trying to put the needle through the dura - an intentional dural puncture.
Either of these types of dural puncture can cause a headache. About 1% of people having a spinal anaesthetic or epidural for childbirth will get a headache afterwards.
Why does a dural puncture cause a headache?
A Post Dural Puncture Headache (PDPH) occurs after a hole is made in the dura:
- Post means after
- Dural puncture is a hole in the dura
There are several ideas about why a hole in the dura causes a headache - these are described below.
The hole in the dura might allow CSF (the clear fluid around the brain and spinal cord) to leak and this may cause a headache by reducing the fluid cushion around the brain.
The blood vessels around the brain and spinal cord may temporarily enlarge (dilate) due to the hole in the dura
What does a dural puncture headache feel like?
There are things about a dural puncture headache that can help the anaesthetic doctor decide that this is the likely cause of your pain.
People experiencing a dural puncture headache will often notice a headache that is worse when they are sitting up or standing and better when lying down ("positional"). It will usually start within the first few days after the epidural or spinal.
They may also notice other symptoms - they may have a stiff or sore neck, feel nauseated (like they want to vomit), and may be bothered by lights or noises. Some people also notice changes in their vision or hearing.
These symptoms can range from mild (where you can get on with your day to day activities) to significant (where you are stuck lying in bed due to pain). The symptoms will often make caring for a newborn (and other children or family members) challenging.
There are lots of other reasons why people might get a headache after having a baby. The anaesthetic doctor may be able to diagnose the cause of your headache by talking to you or they may want tests (such as blood tests or scans) before making the diagnosis.
What do you do if you get a headache?
If you are still in hospital, let the midwife or nurse caring for you know and they can contact the anaesthetic team. They will review you to see if they think you have a post dural puncture headache, and recommend treatments (see below).
If you have gone home or to the birth centre, let your lead maternity carer (midwife or obstetrician) or your family doctor (GP) know. They can telephone the hospital anaesthetic service and together make a plan for you.
What treatments are available for a dural puncture headache?
There are several treatment options if you get a dural puncture headache - the anaesthetic doctor caring for you will discuss these with you and your whānau. They will help recommend treatment for you after hearing about your symptoms and how they are affecting you. Often you will start with simple treatments and then you may be recommended to have an Epidural Blood Patch or Sphenopalatine Block (see below) if the simple treatments aren't working or your headache is severe.
Most dural puncture headaches will go away by themselves within a week. If your headache is mild you may be able to use simple treatments while waiting for it go away. These include:
Rest - taking time to be in a comfortable position (often lying in bed)
Pain relief - medications such as paracetamol, anti-inflammatories (like ibuprofen), or opioid medicines (like tramadol)
Caffeine - there is some evidence this might be helpful for dural puncture headaches especially in people who usually drink coffee or other caffeinated beverages.
Epidural Blood Patch
This is a procedure done to try and make the dural puncture headache go away.
It involves repeating the epidural injection process but, instead of putting pain relieving medications through the epidural, a syringe with your own blood is injected instead.
See below for more details about a blood patch procedure.
A sphenopalatine block is a newer treatment that is simple and can improve or resolve dural puncture headaches.
It involves putting local anaesthetic through each nostril in to an area at the back of your nose (a similar location to where a COVID swab is taken).
Once the block is done, most people will find their headache goes away quickly but it may come back several hours later.
Epidural Blood Patch
An Epidural Blood Patch (EBP) is a procedure done to try and fix a dural puncture headache.
An anaesthetic doctor will talk through the procedure, the risks, and the benefits before doing an Epidural Blood Patch. Below is a summary describing what will often happen during the procedure, but the exact process in the hospital where you are being cared for may differ.
A blood patch is done in hospital in an operating theatre, recovery room, or in a room in (or near) delivery suite. If you have returned home or gone to a birth centre, you will need to come back to hospital to have the blood patch done.
There will usually be two doctors involved in the blood patch procedure - one will take a blood sample, and one will perform the epidural procedure.
You will wear a hospital gown and will either sit or lie on your side in bed depending on what you are able to do (sitting might be too sore because of the headache). You may want to go to the toilet before the procedure as you need to lie in bed for an hour or two afterwards. It is also helpful to have someone who can support you to care for your baby during the procedure and the time you are lying in bed.
Your back and the arm where they are taking blood from will be cleaned with antiseptic solution. You will be asked to curl your back around (like you did for the original epidural or spinal procedure) and a sticky drape (like a cloth or raincoat) will be put on your back. Local anaesthetic will be put in to the skin in the lower part of your back to numb the skin. An epidural needle will then be inserted through this numb spot and the anaesthetist will find the epidural space with this needle.
Around this time, the other doctor will take a sample of your blood (20mL - just over a tablespoon) and will give this to the person doing the epidural procedure. They then inject this blood slowly through the epidural needle. You may notice some pain in your lower back or between your shoulder blades while it is being injected - let the anaesthetist know if this happens.
Often your headache will go away very quickly (within seconds or minutes) after the blood patch is performed. You will need to lie down for an hour or two after the procedure. After this time, you can go about your usual activities but may wish to avoid heavy lifting or straining for a couple of days.
If 100 people with a dural puncture headache had an epidural blood patch, 50 to 80 of them would have their headache fixed or improved (50-80% success rate). For those that don't get relief after the first blood patch, around 70% of them will get success with a second blood patch.
It is not entirely clear why a blood patch relieves the headache pain. It may work by plugging the hole in the dura, by increasing the pressure in the CSF (fluid filled space around the brain and spinal cord), or by helping the hole to heal.
Back pain - most common complication, around 25% of people will experience this (1 in 4 people). The back pain usually goes away after a few days.
Making another hole in the dura - just like with the epidural procedure done for pain relief, there is a chance that the blood patch procedure can cause another hole in the dura. This could make the headache worse.
Rare but serious risks - infection, bleeding, nerve damage, allergic reaction. These are uncommon and the anaesthetic team will try their best to avoid these happening to you.