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Postdural puncture headache
Background
Overview
Definition
PDPH is a positional headache that occurs after a dural puncture, typically presenting within 48 hours but can be delayed up to 5 days.
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Pathophysiology
PDPH is thought to be caused by CSF leakage through the dural puncture site, leading to decreased CSF volume and pressure. This results in compensatory cerebral vasodilation and downward traction on pain-sensitive structures within the brain, contributing to the headache.
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Epidemiology
The incidence of PDPH in the general population undergoing lumbar puncture ranges from 2-40%, and can be as high as 50-80% in obstetric patients undergoing spinal anesthesia.
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Risk factors
Risk factors for PDPH include younger age, female sex, lower BMI, low CSF opening pressure, spinal stenosis, and previous PDPH. The size and type of needle used, the number of puncture attempts, and the experience of the practitioner influence the risk of PDPH. Smaller gauge needles and non-cutting needles are associated with a lower incidence of PDPH.
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Disease course
PDPH is characterized by a bilateral, frontal-occipital headache that worsens in the upright position and improves when lying down. Associated symptoms may include neck stiffness, nausea, vomiting, photophobia, auditory disturbances, vertigo, and tinnitus.
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Prognosis and risk of recurrence
PDPH usually resolves spontaneously within one week in most cases, although some may persist longer. Conservative management includes bed rest, hydration, caffeine, and analgesics. In refractory cases, an epidural blood patch may be used.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of postdural puncture headache are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2024), the American Society of Spine Radiology (ASSR/ESRA/SOAP/AIHS/ASRA/OAA 2024), and the British Medical Journal (BMJ 2018).
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Diagnostic investigations
Clinical assessment
As per AIHS/ASRA/ASSR/…/SOAP 2024 guidelines:
Suspect PDPH in patients with headache or neurological symptoms, which may be relieved when lying flat, occurring within 5 days of a neuraxial procedure.
B
Evaluate inpatients after a neuraxial procedure for symptoms of PDPH. Instruct outpatients to report symptoms of PDPH to their physicians.
A
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Diagnostic imaging
Medical management
Supportive care: as per ACR 2024 guidelines, recognize that PDPHs are typically self-limited, with most symptoms fully resolving within 1 week without any treatment. Offer conservative medical management for the initial management of PDPH.
B
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Oral analgesics
Caffeine
Agents with no evidence for benefit
Nonpharmacologic interventions
Therapies with no evidence for benefit
As per AIHS/ASRA/ASSR/…/SOAP 2024 guidelines:
Insufficient evidence to support the routine use of the following in the management of PDPH:
bed rest
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abdominal binders
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aromatherapy
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acupuncture
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Consider offering bed rest as a temporizing measure for symptomatic relief.
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Therapeutic procedures
Epidural blood patch, indications
As per ACR 2024 guidelines:
Consider performing an epidural blood patch in patients with severe PDPH or PDPH not beginning to resolve by 2-3 days after dural puncture.
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Perform an epidural blood patch procedure directed at the level of dural puncture in patients with PDPH not improving after after 72 hours of dural puncture.
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Epidural blood patch (technical consideration)
Epidural blood patch (postprocedural care)
Greater occipital nerve block
Sphenopalatine ganglion block
Fibrin glue
Preventative measures
Choice of needle: as per AIHS/ASRA/ASSR/…/SOAP 2024 guidelines, use non-cutting spinal needles routinely for lumbar puncture in all populations.
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Prophylactic spinal analgesia
Prophylactic epidural blood patch
Measures with no evidence for benefit