Confronting Postdural Puncture Headache in Clinical Practice

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New evidence emphasizes the use of smaller-gauge needles to help prevent postdural puncture headache.
New evidence emphasizes the use of smaller-gauge needles to help prevent postdural puncture headache.

Postdural puncture headache (PDPH) is a known consequence of lumbar puncture used for the diagnosis of neurological disorders, as well as during epidural anesthesia.1 The International Classification of Headache Disorders published in 2004 defined PDPH as a "positional" headache occurring within 7 days of postdural puncture (PDP) that worsens with standing and is relieved on lying down.2

In 2016, however, Monserrate et al3 explored suggested mechanisms of PDPH based on the idea that factors contributing to the lowering of cerebrospinal fluid (CSF) during PDP (such as sitting and high-volume extraction) cause meningeal vasodilation that affects local nerves when in the upright position. They concluded that although sitting may be associated with a transient risk for PDPD, it is likely not the cause of PDPH that occurs 24 hours or more after the procedure, which is likely a result of CSF leakage. They also found that collection of 17 to 30 mL of CSF was safe and least likely to result in PDPH.

Neurology Advisor spoke with Sarah E. Vollbracht, MD, clinical director of the Montefiore Headache Center in New York City, to provide a more in-depth perspective on the prevention and treatment of PDPH in the clinical setting.

Neurology Advisor: What is the frequency of PDPH in clinical practice?

Dr Vollbracht: PDPH is a commonly encountered complication of procedures that can result in dural puncture, whether in the setting of diagnostic procedures or as a complication of spinal or epidural anesthesia. The frequency of PDPH varies largely based on both patient and procedure characteristics. PDPH is more common in young, thin women; in patients with a prior history of PDPH; and in patients with a history of a chronic headache disorder.

Neurology Advisor: Are there any measures that effectively reduce risk for PDPH?

Dr Vollbracht: Needle size and shape, bevel orientation, and stylet replacement are all measures that can be considered to reduce the risk for PDPH. Of these, the needle size is likely the most important factor; smaller-gauge needles carry a lower risk for the development of PDPH. In general, 25- to 27-gauge needles should be used for spinal anesthesia. Lumbar puncture requires a larger gauge needle (22 gauge) to accurately measure CSF pressure and collect fluid. Atraumatic needles, which separate the fibers rather than tear them, are also thought to reduce the risk for PDPH by reducing the risk for damage to the dura. Atraumatic needles are more expensive than traumatic/cutting needles, and so are often not available. Procedure technique may also play a role in ensuring that the bevel of the needle runs parallel to the fibers on insertion, so removal creates a smaller dural opening, thereby reducing the risk for PDPH. The stylet should also be reinserted before removing the needle.

Neurology Advisor: Reviews by Park et al4 and Arevalo-Rodriguez et al5 have shown a lack of evidence supporting bed rest for the prevention of PDPH. What has your clinical experience shown?

Dr Vollbracht: In my experience, bed rest, hydration, and patient positioning during the procedure do not reduce the incidence of PDPH, but may be reassuring and more comfortable for the patient. The most important modifiable factors that can reduce the risk for PDPH are needle size and shape, bevel orientation, and stylet replacement.

Neurology Advisor: How do you prefer to treat PDPH?

Dr Vollbracht: PDPH is usually a self-limited condition, with resolution in nearly 75% of patients6,7 within 1 week.6,7 I generally reassure patients that they will likely get better within a few days without any intervention and encourage rest, hydration, and symptomatic treatment with simple analgesics, nonsteroidal anti-inflammatory medications, and antiemetics if indicated. If the headache is particularly debilitating and interferes with their ability to function, I will arrange for an epidural blood patch, which is generally done by radiology or anesthesiology and can be performed as an outpatient procedure. If a patient has been admitted to the hospital, I will treat with intravenous hydration and caffeine sodium benzoate, along with symptomatic treatment, all of which may provide symptom relief without necessarily affecting prognosis, and will arrange for an epidural blood patch if the patient does not respond to intravenous and oral medications.

References

1. Bezov D, Lipton RB, Ashina S, et al. Post-dural puncture headache: part I diagnosis, epidemiology, etiology, and pathophysiology. Headache. 2010;50:1144-1152.

2. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24 Suppl 1:9-160.

3. Monserrate AE, Ryman DC, Ma S, et al; for the Dominantly Inherited Alzheimer Network. Factors associated with the onset and persistence of post–lumbar puncture headache. JAMA Neurol. 2015;72:325-332.

4. Park S, Kim K, Park M, et al. Effect of 24-hour bed rest versus early ambulation on headache after spinal anesthesia: systematic review and Meta-analysis. Pain Manag Nurs. 2018:19;267-276.

5. Arevalo-Rodriguez I, Ciapponi A, Roqué i Figuls M, Muñoz L, Bonfill Cosp X. Posture and fluids for preventing post-dural puncture headache. Cochrane Database Syst Rev. 2016;3:CD009199.

6. Dripps RD, Vandam LD. Long-term follow‐up of patients who received 10,098 spinal anesthetics: Failure to discover major neurological sequelae. J Am Med Assoc. 1954;156:1486-1491.

7. Bezov D, Ashina S, Lipton R. Post-dural puncture headache: Part II – prevention, management, and prognosis. Headache. 2010;50:1482-1498.

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