Management of Post-Dural Puncture Headache

Mechanism:
 CSF leakage through a needle or catheter induced dural defect occurs faster than new CSF production which causes traction on
intracranial contents when the patient is in an upright position.
 In response to stretching of intracranial contents, cerebral vessels vasodilate
 Pain is referred via trigeminal n. (frontal region), glossopharyngeal n. (occiput region), vagus n. (neck region) and cervical
nerves (shoulders).

Defining Factors:
 Positional headache that worsens in the upright position and disappears within 30min of resuming the recumbent position
 Onset is typically w/in 24-48H after dural puncture but can be delayed up to 12 days
 Headache is dull or throbbing in nature and may start in the frontal or occipital region, may radiate to the neck and shoulders,
in some cases may be assoc. with neck stiffness
 Any maneuvers that increase intracranial pressure (coughing, sneezing, straining) may worsen symptoms

Risk factors: >10 yrs, peaks around 15yrs and declines after 50yrs, Females > Males, Pregnant women, low BMI , Needle gauge and
type (cutting needles > pencil point)

Management is dependent on severity: In pregnant women, severity is dependent on Mom’s ability to care for baby

Conservative Treatment (no severe HA, able to care for baby, able to breastfeed)
 Aggressive hydration
 Simple analgesics
 Cerebral vasoconstrictors: Caffeine, Sumatriptan
 Fioricet (acetaminophen, caffeine, butalbital): caffeine combined with acetaminophen helps increase its pain relieving effects,
butalbital helps decrease anxiety
 Cosyntropin/Hydrocortisone: stimulate the adrenal gland and increase CSF secretion
o In a randomized controlled study of 60 patients with PDPH following spinal anesthesia for cesarean section,
hydrocortisone given for 48 h significantly reduced the severity of PDPH in the study group. In another randomized
controlled study of 90 patients with ADP, Cosyntropin 1 mg IV reduced PDPH from 69 to 33%; and the need for EBP from
30% to 11%
Definitive Treatment (HA is severe and intolerable, unable to care for baby)
 Epidural Blood Patch: autologous blood is injected into the epidural space
o Spreads cephalad and caudally and increases the pressure in the epidural space which compresses the thecal sac and
increases CSF pressure. CSF is a procoagulant and helps the injected blood to occlude the hole in the dura which
prevents further CSF leakage
o Contraindications: fever, local infection, coagulopathy, patient refusal
o Procedure: Under full aseptic precautions the epidural space is identified, either at the level of original puncture or one
space lower. Another anesthetist, also with full aseptic precautions, performs venipuncture and hands over the blood to
be injected. The volume of blood to be injected is typically 20-30ml. It is slowly injected into the epidural space till the
patient reports a feeling of pressure or pain in her back or legs. After the procedure, the patient is advised to lie flat for
at least 2 h and avoid vigorous activity or straining for a few days.
o It is recommended that the EBP should not be performed too soon after dural puncture. A randomized study by Loeser
found that performing EBP after 24 h reduced the failure rate from 71% to 4% in a study of 66 EBP. The initial outcome
from an EBP is between 70 and 98% but up to 40% need a second EBP, and occasionally even a third.
o Complications: backache, transient bradycardia, radiculitis, arachnoiditis, aseptic meningitis, cranial nerve paralysis,
seizures and cauda equina syndrome. A recent Cochrane review concluded that EBP is beneficial for PDPH compared to
conservative treatment.
o It should be remembered that PDPH is not only a disabling condition but, if left untreated, can also lead to complications
such as cranial nerve palsies, subdural hematoma and cortical venous thrombosis