A post-dural puncture headache (PDPH) occurs after intentional (in the case of spinal anesthesia) or accidental (in the case of epidural anesthesia) puncture of the dura mater. The resulting loss in CSF pressure leads to traction on the meninges and a severe headache, which is often positional and accompanied by nausea.
Most patients respond to conservative treatment with bed rest and non-opioid analgesics, such as NSAIDS or acetaminophen. Approximately 25% of patients will experience a spontaneous recovery within 2 days and almost 75% of patients will experience a spontaneous recovery within 7 days. Unfortunately, small number of patients (~4%) will continue to complain of symptoms for more than 6 months. Many sources recommend caffeine as a treatment for PDPH; however, there is limited empiric data to support this approach.
In patients with severe pain or in patient in whom the PDPH and associated symptoms overly interfere with daily activity, and epidural blood patch may be performed.
The best prevention of a PDPH is to avoid puncture of the dura mater. If the patient requires a dura puncture, multiple studies have suggested that large spinal needles are associated with an increased risk of a PDPH. Thus, the smallest possible needle should always be used. Quincke needles, which have a cutting bevel, are also associated with a higher risk of PDPH as compared to Whitacre and Sprotte needles, which have a conical (Sprotte), diamond (Whitacre) or “pencil point” tips.
- D K Turnbull, D B Shepherd Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth: 2003, 91(5);718-29