Postdural Puncture Headache (PDPH)


Article Author:
Michael Plewa


Article Editor:
Russell McAllister


Editors In Chief:
Michael Labanowski


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
6/15/2019 8:01:20 PM

Introduction

Postdural puncture headache (PDPH) is a potential expected complication of a lumbar puncture, with symptoms related to traction on pain-sensitive structures from low cerebrospinal fluid (CSF) pressure (intracranial hypotension) following a leak of CSF at the puncture site.[1][2][3]

Etiology

Causes of PDPH include dural puncture during a lumbar puncture (LP), diagnostic myelography, a subarachnoid (spinal) block, or following unintentional dural puncture from epidural anesthesia or injection for pain. Similar low-CSF pressure (intracranial hypotension) symptoms can also occur spontaneously or following craniotomy, placement of ventricular shunts, brain/spinal trauma, or spinal surgery. Risk factors for PDPH include dehydration, systemic illness, prior headaches, use of a large caliber or cutting needle, female gender, pregnancy, younger age, the use of a cutting or larger bore spinal needle, or inexperienced proceduralist.[4][5]

Epidemiology

PDPH is more common in women, younger ages (20 to 40 years), those with prior headaches (especially prior PDPH), and low body mass index. PDPH is uncommon in the elderly, likely because of brain atrophy. Other risk factors include caliber of the needle, use of a cutting needle, especially if inserted or rotated perpendicular to the long axis of the dural fibers, whereas use of a small caliber pencil-tipped needle decreases the risk, as does reinsertion of the stylet. The experience of the physician, the number of punctures, and removal of large amounts of CSF fluid may or may not be related to PDPH incidence. Positioning during (sitting versus decubitus) or after (bedrest or upright) the LP is unrelated to PDPH.

Incidence has been estimated to be quite variable in the literature, but may be approximately 10% to 40% of LP procedures, but can be as low as 2% when small gauge (less than or equal to 24 gauge) non-cutting needles are used. Symptoms of PDPH typically occur within 48 to 72 hours of LP but can be delayed for months afterward.[6][7]

Pathophysiology

PDPH occurs with low cerebrospinal fluid volume from a leak at the site of the dural puncture that exceeds spinal fluid production resulting in low CSF pressure (intracranial hypotension). Traction precipitates symptoms on pain-sensitive structures such as the meninges, blood vessels (especially veins and sagittal or transverse sinuses), cranial nerves, and upper cervical nerves. Sagging of the brain downward in the upright position contributes to orthostatic symptoms. Magnetic resonance imaging (MRI) studies have demonstrated evidence of vascular dilation (engorgement of venous sinuses, enhancement of meningeal layers and enlargement of the vascular pituitary gland) to compensate for the diminished volume of CSF. Since physical maneuvers which increase intracranial venous volume (such as coughing, laughing, Valsalva maneuver or internal jugular compression) worsen a headache suggesting that PDPH symptoms are at least in part due to the compensatory central venous dilation.[8][9]

History and Physical

Symptoms of PDPH include bilateral frontal or an occipital headache worse in the upright position, improved supine, associated with nausea, dizziness, neck pain, visual changes and occasionally tinnitus, hearing loss or radicular symptoms into the arms. Symptoms, especially headache, may also be worse with coughing and Valsalva maneuver, even in the supine position.

Physical examination is usually unremarkable, and the typical patient should not exhibit fever, meningismus, altered mentation or focal neurologic findings. In unusual cases, focal findings might include nystagmus, horizontal diplopia, facial numbness or palsy. Palsy of cranial nerve VI (Abducens) is an uncommon finding that may cause diplopia.  A firm continuous pressure in the abdomen may temporarily improve headache symptoms by indirectly increasing CSF pressure. Pressure on the jugular vein can worsen the headache symptoms. 

Evaluation

Diagnosis of PDPH is clinical, and laboratory studies or imaging are typically not necessary. Severe or persistent cases, especially those which no longer are alleviated with recumbent positioning should prompt neuroimaging to exclude subdural hematoma or cerebral or venous thrombosis.

Lumbar puncture in patients suspected of PDPH is discouraged (since this would likely exacerbate symptoms) but would demonstrate low to even negative (less than zero) CSF opening pressure. CSF may reveal white and red blood cells, elevated protein levels or xanthochromia.

In patients with long-standing PDPH or intracranial hypotension, MRI with gadolinium enhancement may demonstrate descent of the cerebellar tonsils (similar to a Chiari type 1 malformation), effacement of the basilar cisterns, thickening of the meninges, subdural fluid accumulation, venous sinus engorgement and an enlarged pituitary gland. These changes are reversible with treatment. Effacement of the basilar cisterns can also be seen on computerized tomography (CT) brain imaging and could be confused with subarachnoid hemorrhage. CT myelography or MRI of the spine can reveal the location and extent of CSF leak.[10][11]

Treatment / Management

Initial symptom management with simple analgesics, oral or intravenous hydration, and avoidance of the upright position may often be effective. PDPH symptoms can resolve spontaneously within one to two weeks in over two-thirds of patients. In many cases, symptoms are severe and persistent and require intervention.  

There is some evidence to support the use of oral or intravenous caffeine (300 mg to 500 mg in one L of intravenous fluid over one hour) for PDPH, although effects may be transient with high failure and recurrence rates.

Specific treatment of the dural leak may not be required in all cases since spontaneous resolution typically occurs within days to weeks. However, prolonged symptoms and complications have been reported when treatment is not pursued.

The idea of using blood to patch a hole in the dura was described in 1960 by Dr. James Gorley, a surgeon from Pennsylvania.  He described placing small volumes of blood outside the dura to treat PDPH, with very good results.  This later became the concept for the epidural blood patch.

Definitive treatment with an epidural blood patch is recommended when symptoms persist after conservative treatment. For post partum mothers recovering from childbirth and with a high degree of responsibility for caring for their child, a PDPH can be quite disabling.  Many physicians will treat early with an epidural blood patch in these situations.  For this procedure, 10 ml to 30 ml of autologous venous blood is injected by an anesthesiologist into the epidural space at the level of the prior procedure.  This is thought to create a "patch" over the dural puncture and decrease CSF leak, or simply increase the intracranial pressure.  Success rates are higher than 75% to 90%, especially if repeated but can rarely be complicated by back pain, meningeal irritation, radiculopathy, bulbar neuropathy, meningeal infection, hematoma or cauda equina syndrome.

A two to three-day continuous epidural saline infusion may be less effective and have fewer adverse effects than blood patch, but require an indwelling epidural catheter, bedrest, and hospitalization.  This is rarely done.

Multiple experimental treatments have been suggested, including oral or parenteral steroids, intramuscular adrenocorticotrophic hormone (ACTH), oral gabapentin, methylxanthines (through vasoconstriction and decreased central venous volume), such as IV aminophylline (5 mg/kg to 6 mg/kg over 20 min) or oral theophylline (300 mg every six to eight hours), and sumatriptan or other triptans. Several cases have reported the successful use of local injection of cyanoacrylate adhesive or fibrin glue for refractory cases.  Due to high success rates and low complication rates of the epidural blood patch, it remains the gold standard of therapy for PDPH. [12][13][14]

Complications

Rarely, prolonged or severe cases can result in cerebral venous thrombosis, subdural hematoma from traction on dural veins, seizures, hypopituitarism, syringomyelia, herniation, coma, and death.

Deterrence and Patient Education

The most important consideration in preventing PDPH is the use of a small gauge, pencil-tipped, non-cutting spinal needle. There is no evidence to support supplemental fluid or bedrest following procedure to prevent PDPH.  Intravenous aminophylline, adrenocorticotrophic hormone (ACTH), or epidural morphine may reduce the incidence of PDPH, but further investigation is needed to prove efficacy.

Pearls and Other Issues

 

 

Enhancing Healthcare Team Outcomes

PDPH can lead to longer hospitilizations and higher healthcare costs. Many measures have been suggested to help prevent the disorder but, thus far, none have been shown to be effective in randomized, controlled trials. The use of ultrasound does show promise as it can accurately predict the depth of the epidural space but until randomized studies are done, the utility of ultrasound remains academic.[15]

Many pharmaceutical agents have been investigated for prevention of PDPH but, so far, most have not lowered the risk of the condition. There even remains controversy about prophylactic bed rest and hydration prior to the procedure. [16][17]

Outcomes

To date, once PDPH is diagnosed, the management should incorporate an interprofessional team of experts including a neurologist, a pharmacist, intensivist, and an anesthesiologist. Anyone with a headache that is not improving or has neurological signs should have a referral to a neurologist.  Monitoring with bed rest and offering hydration are key treatments. Besides a blood patch, many headache drugs have been used to manage PDPH. The pharmacist should be aware of the current literature on these agents since not all are effective in resolving PDPH. (Level V) [18][19]

Most of the published literature on PDPH includes case reports and short-term reports with conflicting data. More randomized studies are necessary to determine the ideal method for preventing PDPH and how to treat it once the condition has developed. (Level V)[20][21]

Treatment with an epidural blood patch remains the gold standard at this time.


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Postdural Puncture Headache (PDPH) - Questions

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A patient is undergoing a lumbar puncture (LP) for further evaluation of possible multiple sclerosis. She is terrified of a post-LP headache. You tell her you will use a small needle, with the bevel inserted parallel to the dural fibers, and that you will replace the stylet will before removing the needle. She continues to fear the procedure. What else can you offer to minimize the risk of developing a post-LP headache?



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Which of the following factors has the greatest impact on the development of a headache after a lumbar puncture (LP)?



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Which of the following accurately describes a post-lumbar puncture headache (PLPH)?



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Which factor increases the risk of developing a post dural puncture headache?



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Which of the following is not a typical feature of a postdural puncture headache?



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Postdural puncture headache is most commonly associated with what type of needle?



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Which is an inappropriate treatment of a post lumbar puncture headache?



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Which of the following is NOT a risk factor for post lumbar puncture headache?



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What is the cause of postdural puncture headache?



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What would be seen on MRI of the brain in a patient with a post dural puncture headache?



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A 26 year old female with possible multiple sclerosis needs a lumbar puncture to complete her evaluation. She has heard about spinal headaches and is hesitant. She is reassured that proper technique minimizes the risk but she is still concerned. Which of the following is most likely to decrease the chance of post-dural puncture headache?



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Which of the following is the most important factor for development of post dural puncture headache?



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Select the correct statement about post dural puncture headache (PDPH).



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Which of the following patients is most likely to develop a post-dural puncture headache?



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A 35 year old woman with migraine history has a different type of headache after her lumbar puncture. Which of the following characteristics suggests postdural puncture headache (PDPH)?



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A 17-year-old woman has a several week history of post-dural puncture headache (PDPH) has declined blood patch. She now has a severe unrelenting headache, unrelieved with changes in body position. She also has mild alteration in mentation. What is the most appropriate next step?



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Which is the most important in preventing post-dural puncture headache (PDPH)?



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Postdural Puncture Headache (PDPH) - References

References

Tubben RE,Jain S, Epidural Blood Patch null. 2018 Jan     [PubMed]
Zorrilla-Vaca A,Mathur V,Wu CL,Grant MC, The Impact of Spinal Needle Selection on Postdural Puncture Headache: A Meta-Analysis and Metaregression of Randomized Studies. Regional anesthesia and pain medicine. 2018 Jul     [PubMed]
Uchino K, Review: Atraumatic lumbar puncture needles reduce postdural puncture headache compared with conventional needles. Annals of internal medicine. 2018 Mar 20     [PubMed]
Nath S,Koziarz A,Badhiwala JH,Alhazzani W,Jaeschke R,Sharma S,Banfield L,Shoamanesh A,Singh S,Nassiri F,Oczkowski W,Belley-Côté E,Truant R,Reddy K,Meade MO,Farrokhyar F,Bala MM,Alshamsi F,Krag M,Etxeandia-Ikobaltzeta I,Kunz R,Nishida O,Matouk C,Selim M,Rhodes A,Hawryluk G,Almenawer SA, Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis. Lancet (London, England). 2018 Mar 24     [PubMed]
Veličković I,Pujic B,Baysinger CW,Baysinger CL, Continuous Spinal Anesthesia for Obstetric Anesthesia and Analgesia. Frontiers in medicine. 2017     [PubMed]
Akdemir MS,Kaydu A,Yanlı Y,Özdemir M,Gökçek E,Karaman H, The Postdural Puncture Headache and Back Pain: The Comparison of 26-gauge Atraucan and 26-gauge Quincke Spinal Needles in Obstetric Patients. Anesthesia, essays and researches. 2017 Apr-Jun     [PubMed]
Plewa MC,Dulebohn SC, Postdural Puncture Headache (PDPH) null. 2018 Jan     [PubMed]
Gaiser RR, Postdural Puncture Headache: An Evidence-Based Approach. Anesthesiology clinics. 2017 Mar     [PubMed]
Salzer J,Rajda C,Sundström P,Vågberg M,Vécsei L,Svenningsson A, How to minimize the risk for headache? A lumbar puncture practice questionnaire study. Ideggyogyaszati szemle. 2016 Nov 30     [PubMed]
Stanhope E,Foulds L,Sayed G,Goldmann U, Diagnosing causes of headache within the postpartum period. Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology. 2018 Jul     [PubMed]
Kurnutala LN,Kim D,Sayeed H,Sibai N, Persistent Spinal Headache After Removal of Intrathecal Drug Delivery System: A Case Report and Review of Literature. Anesthesiology and pain medicine. 2015 Oct     [PubMed]
Baratloo A,Rouhipour A,Forouzanfar MM,Safari S,Amiri M,Negida A, The Role of Caffeine in Pain Management: A Brief Literature Review. Anesthesiology and pain medicine. 2016 Jun     [PubMed]
Katz D,Beilin Y, Review of the Alternatives to Epidural Blood Patch for Treatment of Postdural Puncture Headache in the Parturient. Anesthesia and analgesia. 2017 Apr     [PubMed]
Bendel MA,Moeschler SM,Qu W,Hanley E,Neuman SA,Eldrige JS,Hoelzer BC, Treatment of Refractory Postdural Puncture Headache after Intrathecal Drug Delivery System Implantation with Epidural Blood Patch Procedures: A 20-Year Experience. Pain research and treatment. 2016     [PubMed]
Vadhera RB,Babazade R,Suresh MS,Alvarado MC,Cruz AL,Belfort MA, Role of transcranial Doppler measurements in postpartum patients with post-dural puncture headache: a pilot study. International journal of obstetric anesthesia. 2017 Feb     [PubMed]
Wu C,Lian Y,Guan D,Wang L,Miao Y,Xie N,Chen Y,Zheng Y, A Multicenter Clinical Study on Treating Post-Dural Puncture Headache with an Intravenous Injection of Aminophylline. Pain physician. 2016 Jul     [PubMed]
Basurto Ona X,Osorio D,Bonfill Cosp X, Drug therapy for treating post-dural puncture headache. The Cochrane database of systematic reviews. 2015 Jul 15     [PubMed]
Thew M,Paech MJ, Management of postdural puncture headache in the obstetric patient. Current opinion in anaesthesiology. 2008 Jun     [PubMed]
Rusch R,Schulta C,Hughes L,Withycombe JS, Evidence-Based Practice Recommendations to Prevent/Manage Post-Lumbar Puncture Headaches in Pediatric Patients Receiving Intrathecal Chemotherapy. Journal of pediatric oncology nursing : official journal of the Association of Pediatric Oncology Nurses. 2014 Jul     [PubMed]
Deng J,Wang L,Zhang Y,Chang X,Ma X, Insertion of an intrathecal catheter in parturients reduces the risk of post-dural puncture headache: A retrospective study and meta-analysis. PloS one. 2017     [PubMed]
Barreras P,Benavides DR,Barreras JF,Pardo CA,Jani A,Faigle R,Bahouth MN, A dedicated lumbar puncture clinic: performance and short-term patient outcomes. Journal of neurology. 2017 Oct     [PubMed]

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