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Post-dural (post-lumbar) puncture headache: Risk factors and clinical features

Post-dural (post-lumbar) puncture headache (PDPH) is a common and incapacitating complication following an intentional puncture of the dura-arachnoid, whether for the purposes of diagnosis, therapy, or spinal anesthesia, or inadvertently during an epidural procedure (1–5). The typical feature of PDPH is the postural character of the pain, that is when the individual assumes an upright position (e.g. sitting, standing). According to the diagnostic criteria of the International Headache Society (IHS) (6), the headache appears up to the fifth day after puncture and disappears spontaneously within a week, or up to 48 hours after an epidural blood patch. It is accompanied by at least one of the…

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 Preventing Post-Lumbar Puncture Headache

Among nonmodifiable factors, older age is associated with lower incidence of post-lumbar puncture headache, while female sex, lower body mass index, and history of headache might be associated with increased risk. The use of atraumatic, noncutting needles is the most effective intervention for post-lumbar puncture headache prevention. These needles are not more difficult to use than cutting needles. Other commonly recommended measures (eg, fluid supplementation, caffeine) appear unhelpful, and some (eg, bed rest) may worsen post-lumbar puncture headache.

Articles of Interest

Lumbar Puncture: It Is Time to Change the Needle

The data appearing in the current literature imply that LP should be performed with the 22-G or smaller atraumatic needle. The technique is easy to learn, and is a simple way to decrease PLPH and probably the risk of life-threatening intracranial complications such as subdural hematoma following LP. Bed rest after LP is currently the common practice which was not proven so far to decrease the incidence of PLPH.

Post LP Headache

On my first month in the Parkland ED, I saw multiple patients with post-lumbar puncture headaches and even iatrogenically caused one myself. Often I found myself wondering what proven preventative measures during an LP decrease the incidence of such headaches, what could I have done better, and what literature supports treatment of post-lumbar puncture headaches in the emergency department.

Post Lumbar Puncture Headache

Usually frontal, burning, radiates to neck / shoulders... N.B. Headache minimal or absent supine alleviated by lying down.

Post Lumbar Puncture Headache - Peds

Post Lumbar Puncture (AKA, Post Dural Puncture) Headache is one of the most common complications of the LP.

Post Lumbar Puncture Headaches

t was noticed early on that patients with “traumatic taps” or “bloody taps” had a lower incidence of post-LP headaches. It has been theorized that this may be due to the patient’s own coagulation system helping form a patch over the hole created by the needle in the dura. Once the post-LP headache has already set in, a blood patch made by injecting 10-30 mLs of the patient’s blood into the epidural space can cause resolution of symptoms in 85-98% of cases if done in the first 24 hours [10].

Post-Dural Puncture Headache

The best way to treat PDH is to prevent it from developing. Techniques proven to reduce risk include higher gauge needle use, atraumatic needle use, reduced LP attempts, and replacing stylet prior to removal. Patients with PDPH refractory to standard therapy should be considered for a blood patch.

The perils of puncture: post lumbar puncture headaches & what to do about them

Headaches are the most common complication of doing a lumbar puncture (LP). Let’s dive into what causes them, how to prevent them, and what to do when patients come back suffering from a post-LP headache.

Trick of the trade: Minimizing post-LP headache

Reinsert the stylet in the needle prior to needle removal. This causes fewer post-LP headaches with absolute risk reduction of 11%. The theory is than arachnoid strand may flow into the needle during CSF collection. Removing the needle without the stylet may “pull” the strand through the dura, causing a persistent CSF leak.

Trick of the Trade: Reducing post-LP headache risk

22G or 25G atraumatic spinal needle The atraumatic spinal needles, also known as Sprotte needles, have a more blunt tip and often require a larger gauge needle to first puncture the skin. If using a 25G needle (which is a bit flimsy), I use a regular 18G needle to puncture the skin and soft tissue first (acting as a trocar), then I thread the 25G spinal needle through.

Resources

Spinal CSF Leak Foundation

Our mission at the Spinal CSF Leak Foundation is to reduce the suffering of any person affected by spinal cerebrospinal fluid (CSF) leak and/or intracranial hypotension. With the right diagnosis and access to the right testing and treatments, more patients will have an improved quality of life. is to reduce the suffering of any person affected by spinal cerebrospinal fluid (CSF) leak and/or intracranial hypotension. With the right diagnosis and access to the right testing and treatments, more patients will have an improved quality of life.