Post-dural-puncture headache (PDPH) is a complication of puncture of the

dura mater In neuroanatomy, dura mater is a thick membrane made of dense irregular connective tissue that surrounds the brain and spinal cord. It is the outermost of the three layers of membrane called the meninges that protect the central nervous syste ...

(one of the membranes around the

brain The brain is an organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It consists of nervous tissue and is typically located in the head ( cephalization), usually near organs for special ...

and

spinal cord The spinal cord is a long, thin, tubular structure made up of nervous tissue, which extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column (backbone). The backbone encloses the central canal of the spin ...

). The headache is severe and described as "searing and spreading like hot metal", involving the back and front of the head and spreading to the neck and shoulders, sometimes involving neck stiffness. It is exacerbated by movement and sitting or standing and is relieved to some degree by lying down. Nausea, vomiting, pain in arms and legs, hearing loss,

tinnitus Tinnitus is the perception of sound when no corresponding external sound is present. Nearly everyone experiences a faint "normal tinnitus" in a completely quiet room; but it is of concern only if it is bothersome, interferes with normal hearin ...

vertigo Vertigo is a condition where a person has the sensation of movement or of surrounding objects moving when they are not. Often it feels like a spinning or swaying movement. This may be associated with nausea, vomiting, sweating, or difficulties ...

, dizziness and paraesthesia of the scalp are also common. PDPH is a common side effect of

lumbar puncture Lumbar puncture (LP), also known as a spinal tap, is a medical procedure in which a needle is inserted into the spinal canal, most commonly to collect cerebrospinal fluid (CSF) for diagnostic testing. The main reason for a lumbar puncture is to ...

and

spinal anesthesia Spinal anaesthesia (or spinal anesthesia), also called spinal block, subarachnoid block, intradural block and intrathecal block, is a form of neuraxial regional anaesthesia involving the injection of a local anaesthetic or opioid into the suba ...

. Leakage of

cerebrospinal fluid Cerebrospinal fluid (CSF) is a clear, colorless body fluid found within the tissue that surrounds the brain and spinal cord of all vertebrates. CSF is produced by specialised ependymal cells in the choroid plexus of the ventricles of the bra ...

causes reduced fluid levels in the brain and spinal cord. Onset occurs within two days in 66% of cases and three days in 90%. It occurs so rarely immediately after puncture that other possible causes should be investigated when it does. Using a pencil point needle rather than a cutting spinal needle decreases the risk. The size of the pencil point needle does not appear to make a difference. PDPH is estimated to occur in between 0.1% and 36% people following dural puncture.

Signs and symptoms

PDPH typically occurs hours to days after puncture and presents with symptoms such as

headache Headache is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches. Headaches can occur as a resul ...

(which is mostly bi-frontal or occipital) and

nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the ...

that typically worsen when the patient assumes an upright posture. The headache usually occurs 24–48 hours after puncture but may occur as many as 12 days after. It usually resolves within a few days but has been rarely documented to take much longer.

Pathophysiology

PDPH is thought to result from a loss of

into the epidural space. A decreased

hydrostatic pressure Fluid statics or hydrostatics is the branch of fluid mechanics that studies the condition of the equilibrium of a floating body and submerged body " fluids at hydrostatic equilibrium and the pressure in a fluid, or exerted by a fluid, on an i ...

in the subarachnoid space then leads to traction to the meninges with associated symptoms.

Diagnosis

Differential diagnosis

Although in very rare cases the headache may present immediately after a puncture, this is almost always due to another cause such as increased intracranial pressure and requires immediate attention.

Prevention

Using a pencil point rather than a cutting spinal needle decreases the risk. The size of the pencil point needle does not appear to make a difference, while smaller cutting needles have a low risk compared to larger ones. Modern, atraumatic needles such as the Sprotte or Whitacre spinal needle leave a smaller perforation and reduce the risk for PDPH. However, the evidence that atraumatic needles reduce the risk of post-dural puncture headache (PDPH) without increasing adverse events such as paraesthesia or backache is moderate-quality and further research should be done.

Morphine Morphine is a strong opiate that is found naturally in opium, a dark brown resin in poppies ('' Papaver somniferum''). It is mainly used as a pain medication, and is also commonly used recreationally, or to make other illicit opioids. Ther ...

, cosyntropin, and aminophylline appear effective in reducing post dural puncture headaches. Evidence does not support the use of bed rest or intravenous fluids to prevent PDPH.

Treatment

Some people require no other treatment than pain medications and

bed rest Bed rest, also referred to as the rest-cure, is a medical treatment in which a person lies in bed for most of the time to try to cure an illness. Bed rest refers to voluntarily lying in bed as a treatment and not being confined to bed because of ...

. A 2015 review found tentative evidence to support the use of

caffeine Caffeine is a central nervous system (CNS) stimulant of the methylxanthine class. It is mainly used recreationally as a cognitive enhancer, increasing alertness and attentional performance. Caffeine acts by blocking binding of adenosine t ...

. Vigorous hydration is routinely encouraged in postpartum patients as a noninvasive, low-risk therapy. Pharmacological treatments as; gabapentin, pregabalin, neostigmine/atropine, methylxanthines, and triptans. Minimally invasive procedures as; bilateral greater occipital nerve block or sphenopalatine ganglion block. Persistent and severe PDPH may require an

epidural blood patch An epidural blood patch (EBP) is a surgical procedure that uses autologous blood in order to close one or many holes in the dura mater of the spinal cord, usually as a result of a previous lumbar puncture or epidural. The procedure can be used t ...

. A small amount of the person's

blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in th ...

is injected into the epidural space near the site of the original puncture; the resulting blood clot then "patches" the meningeal leak. EBP is effective, and further intervention is rarely necessary. 25-35% of patients suffer from transient back pain after EBP. More rare complications of EBP include misplacement of blood leading to spinal subdural hematoma or intrathecal injection and arachnoiditis, infection with subdural abscess, facial nerve paralysis, spastic paraparesis and cauda equina syndrome.

Epidemiology

Estimates for the overall incidence of PDPH vary between 0.1% and 36%. It is more common in younger patients (especially in the 18–30 age group), females (especially those who are pregnant), and those with a low

body mass index Body mass index (BMI) is a value derived from the mass (weight) and height of a person. The BMI is defined as the body mass divided by the square of the body height, and is expressed in units of kg/m2, resulting from mass in kilograms and he ...

(BMI). The low prevalence in elderly patients may be due to a less stretchable dura mater. It is also more common with the use of larger diameter needles. A 2006 review reported an incidence of: * 12% if a needle between and is used; * 40% if a needle between and is used; and * 70% if a needle between and is used. On the Birmingham gauge, these correspond to the values 27–24G, 22–20G and 19–16G. PDPH is roughly twice as common in lumbar puncture than spinal anaesthesia, almost certainly due to the atraumatic needles used in spinal anaesthesia.

References

External links

{{Headache Headaches