FFS: Post Dural Puncture Headache

Pathophysiology

Mechanism

• Loss of CSF leads to reduced brain buoyancy, causing traction on pain-sensitive intracranial structures.
• Adenosine-mediated venodilatation may also contribute.

Risk Factors

• Younger age
• Obstetric patients
• Use of large-bore needles (e.g. epidural needle)

Clinical Features

History

• Onset typically within 24–72 hours of dural puncture
  • 65% present <24 hours
  • 90% present <3 days
• Headache characteristics:
  • Postural: relieved lying down, worsens when upright
  • Location: frontal or occipital (may also be temporal or nuchal)
• Associated symptoms:
  • Nausea, vomiting
  • Tinnitus or hearing loss
  • Photophobia

Examination

• Usually normal
• Abnormal findings (e.g. fever, neck stiffness) should prompt investigation for meningitis, spinal epidural abscess, or other causes
• Rarely: cranial nerve palsies (e.g. CN VI palsy)

Investigations

• Clinical diagnosis
• Consider investigations only to exclude alternative diagnoses

May include:

• FBC and coagulation profile (if coagulopathy suspected)
• CT or MRI: may show dural venous engorgement; often normal

Management

Most cases resolve spontaneously within 7–10 days.

Conservative Measures

1. Rehydration
   • IV fluids if dehydrated
2. Supine rest
3. Simple analgesics
   • Paracetamol
   • NSAIDs
   • Oxycodone (if necessary)
4. Antiemetics as needed
5. Caffeine
   • 500 mg orally or IV once or twice daily
   • Cerebral vasoconstriction may help alleviate symptoms
6. Second-line pharmacological options
   • Hydrocortisone: 200 mg IV bolus, then 100 mg IV TDS for 2 days
   • Gabapentin: 300 mg orally TDS for 4 days

Definitive Management

7. Epidural Blood Patch

• Relieves headache via compression of thecal sac and potential sealing of dural defect
• Success rate: 70–90%

Contraindications

• Fever
• Local infection
• Coagulopathy
• Uncooperative patient

Complications

• Infection (meningitis, epidural abscess)
• Repeat dural puncture
• Back pain

Technique

• Performed by anaesthetics staff under sterile conditions in theatre
• 15–30 mL of autologous blood injected into epidural space near puncture site
• May require repeat patch if headache recurs

Post-Procedural Care

• Monitor pain and temperature 4-hourly for 24 hrs
• Bed rest 4 hours, then gradual mobilisation
• Back pain common; usually resolves within 48 hrs

Disposition

• Refer all potential candidates to Anaesthetics
• Admission to SSU may be appropriate (typically ≤2 days)
• Anaesthetics to manage in conjunction with SSU consultant

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References

Publications

• Brazis PW, Masdeu JC, Biller J. Localization in Clinical Neurology. 8e 2021
• Fuller G. Neurological Examination Made Easy. 6e 2019

FOAMed

• Miers J. Procedure: Lumbar Puncture. LITFL
• Johnson A. August Karl Gustav Bier. LITFL
• Johnson A. J. Leonard Corning. LITFL
• Coni R. Headache classification. LITFL
• Coni R. Headache Essentials. LITFL