Post-dural puncture headache, previously known as post-lumbar puncture headache 4, is a common complication after lumbar puncture (LP), which is often performed for cerebrospinal fluid (CSF) sampling, spinal anesthesia, myelography, etc.
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Epidemiology
Post-dural puncture headaches occur after ~20% (range 2-40%) 3 of dural punctures, most commonly in younger patients (31-50 years) 4.
Risk factors
female 1,4
pregnant patients 1,4
history of headaches 5
fear of LP complications 5
Clinical presentation
An orthostatic headache with onset within 5 days of dural puncture; may be associated with neck stiffness, hearing change, and/or tinnitus 3,4.
Diagnosis
Diagnostic criteria (c.2018) per the International Classification of Headache Disorders, 3rd edition (ICHD-3) from the International Headache Society are 4:
Headache attributed to low CSF pressure (i.e. opening pressure <60 mm CSF) and/or evidence of CSF leakage on imaging).
Dural puncture has been performed.
Headache has developed within five days of the dural puncture.
Not better accounted for by another ICHD-3 diagnosis.
Pathology
The etiology is unclear but thought to occur secondary to a hole/tear in the dura after LP resulting in a CSF leak and craniospinal hypotension 1.
Risk factors
There are a few technique-related factors that can increase the risk of a post-dural puncture headache:
needle size: incidence decreases with small caliber spinal needles 1,3
needle type: atraumatic/pencil-point spinal needles (e.g. Whitacre) when compared to conventional/cutting spinal needles have reduced incidence 1-3
bevel parallel to the spine's long axis during spinal needle insertion 1,3
replacing the stylet before removing the spinal needle 1,5
Treatment and prognosis
Initial treatment is supportive (rehydration, analgesia, caffeine) and most cases (>85%) resolve without further intervention 1,5. If headaches persist and interfere with daily activities then interventions such as epidural blood patch should be considered 1,3. In refractory instances, surgical exploration and fat grafting may also be considered.
Complications
back pain
chronic headache
cranial neuropathy 3
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