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Post-dural puncture headache: pathogenesis, prevention and
treatment
D. K. Turnbull
1
* and D. B. Shepherd
12
1
Academic Anaesthetic Unit, University of Shef®eld, K Floor, Royal Hallamshire Hospital, and
2
Jessop Hospital for Women, Shef®eld S10 2JF, UK
*Corresponding author. E-mail: totleytiger@yahoo.co.uk
Spinal anaesthesia developed in the late 1800s with the work of Wynter, Quincke and Corning.
However, it was the German surgeon, Karl August Bier in 1898, who probably gave the ®rst
spinal anaesthetic. Bier also gained ®rst-hand experience of the disabling headache related to
dural puncture. He correctly surmised that the headache was related to excessive loss of
cerebrospinal ¯uid (CSF). In the last 50 yr, the development of ®ne-gauge spinal needles and
needle tip modi®cation, has enabled a signi®cant reduction in the incidence of post-dural
puncture headache. Though it is clear that reducing the size of the dural perforation reduces
the loss of CSF, there are many areas regarding the pathogenesis, treatment and prevention of
post-dural puncture headache that remain contentious. How does the microscopic pattern of
collagen alignment in the spinal dura affect the dimensions of the dural perforation? How do
needle design, size and orientation in¯uence leakage of CSF through the dural perforation? Can
pharmacological methods reduce the symptoms of post-dural puncture headache? By which
mechanism does the epidural blood patch cure headache? Is there a role for the prophylactic
epidural blood patch? Do epidural saline, dextran, opioids and tissue glues reduce the rate of
CSF loss? This review considers these contentious aspects of post-dural puncture headache.
Br J Anaesth 2003; 91: 718±29
Keywords: anaesthetic techniques, subarachnoid; analeptics, caffeine; complications, dural
puncture; complications, headache
History
Spinal anaesthesia developed in the late 1800s. In 1891,
Wynter and Quincke
95
aspirated cerebrospinal ¯uid (CSF)
from the subarachnoid space for the treatment of raised
intracranial hypertension associated with tuberculous
meningitis. The catheters and trochars used were probably
about 1 mm in diameter and would certainly have led to a
post-dural puncture headache. However, all Quincke and
Wynters' subjects died soon after.
In 1895, John Corning, a New York physician specializ-
ing in diseases of the mind and nervous system, proposed
that local anaesthesia of the spinal cord with cocaine may
have therapeutic properties.
50
Corning injected cocaine
110 mg at the level of the T11/12 interspace in a man to treat
habitual masturbation. Despite being accredited with the
®rst spinal anaesthetic, it is unlikely from his description
and the dose of cocaine that his needle entered the
subarachnoid space.
82
In August 1898, Karl August
Bier,
137
a German surgeon, injected cocaine 10±15 mg
into the subarachnoid space of seven patients, himself and
his assistant, Hildebrandt. Bier, Hildebrandt and four of the
subjects all described the symptoms associated with post-
dural puncture headache. Bier surmised that the headache
was attributable to loss of CSF. By the early 1900s, there
were numerous reports in the medical literature of the
application of spinal anaesthesia using large spinal
needles.
75
Headache was reported to be a complication in
50% of subjects. At that time, the headache was said to
resolve within 24 h.
Ether anaesthesia was introduced into obstetric practice
in 1847, shortly after Morton's public demonstration.
Despite the obvious advantages of regional anaesthesia for
the relief of labour pain, it was not until a Swiss obstetrician
in 1901 used intrathecal cocaine for the relief of pain in the
second stage of labour that regional anaesthesia for
obstetrics was popularized.
49
Though both vomiting and a
high incidence of post-dural puncture headache were noted,
it was the high mortality rate in Caesarean deliveries
performed under spinal anaesthesia (1 in 139) that led to the
abandonment of this technique in the 1930s. The period
from 1930 to 1950 has often been referred to as the `dark
British Journal of Anaesthesia 91 (5): 718±29 (2003)
DOI: 10.1093/bja/aeg231
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ages of obstetric anaesthesia', when natural childbirth and
psychoprophylaxis were encouraged.
In 1951, Whitacre and Hart
59
developed the pencil-point
needle, based on the observations of Greene
53
in 1926.
Developments in needle design since that time have led to a
signi®cant reduction in the incidence of post-dural puncture
headache. However, dural puncture headache remains a
disabling complication of needle insertion into the
subarachnoid space.
Pathophysiology of dural puncture
Anatomy of the spinal dura mater
The spinal dura mater is a tube extending from the foramen
magnum to the second segment of the sacrum. It contains
the spinal cord and nerve roots that pierce it. The dura mater
is a dense, connective tissue layer made up of collagen and
elastic ®bres. The classical description of the spinal dura
mater is of collagen ®bres running in a longitudinal
direction.
53
This had been supported by histological studies
of the dura mater.
93
Clinical teaching based upon this view
of the dura recommends that a cutting spinal needle be
orientated parallel rather than at right angles to these
longitudinal dural ®bres. Orientating the needle at right
angles to the parallel ®bres, it was said would cut more
®bres. The cut dural ®bres, previously under tension, would
then tend to retract and increase the longitudinal dimensions
of the dural perforation, increasing the likelihood of a post-
spinal headache. Clinical studies had con®rmed that post-
dural puncture headache was more likely when the cutting
spinal needle was orientated perpendicular to the direction
of the dural ®bres. However, recent light and electron
microscopic studies of human dura mater have contested
this classical description of the anatomy of the dura
mater.
102
These studies describe the dura mater as consist-
ing of collagen ®bres arranged in several layers parallel to
the surface. Each layer or lamellae consists of both collagen
and elastic ®bres that do not demonstrate speci®c orienta-
tion.
43
The outer or epidural surface may indeed have dural
®bres arranged in a longitudinal direction, but this pattern is
not repeated through successive dural layers. Recent
measurements of dural thickness have also demonstrated
that the posterior dura varies in thickness, and that the
thickness of the dura at a particular spinal level is not
predictable within an individual or between individuals.
102
Dural perforation in a thick area of dura may be less likely to
lead to a CSF leak than a perforation in a thin area, and
may explain the unpredictable consequences of a dural
perforation.
Cerebrospinal ¯uid
CSF production occurs mainly in the choroid plexus, but
there is some evidence of extrachoroidal production. About
500 ml of CSF is produced daily (0.35 ml min
±1
). The CSF
volume in the adult is approximately 150 ml, of which
half is within the cranial cavity. The CSF pressure in the
lumbar region in the horizontal position is between 5 and
15 cm H
2
O. On assuming the erect posture, this increases
to over 40 cm H
2
O. The pressure of the CSF in children
rises with age, and may be little more than a few cm H
2
Oin
early life.
Dura mater and response to trauma
The consequences of perforation of the spinal or cranial
dura are that there will be leakage of CSF. Neurosurgical
experience of dural perforation is that even minor perfor-
ations need to be closed, either directly or through the
application of synthetic or biological dural graft material.
Failure to close the dural perforation may lead to adhesions,
continuing CSF leak, and the risk of infection. There are few
experimental studies of the response of the dura to
perforation.
70
In 1923, it was noted that deliberate dural
defects in the cranial dura of dogs took approximately one
week to close. The closure was facilitated through
®broblastic proliferation from the cut edge of the dura.
Work published in 1959
70
dismissed the notion that the
®broblastic proliferation arose from the cut edge of the dura.
This study maintained that the dural repair was facilitated by
®broblastic proliferation from surrounding tissue and blood
clot. The study also noted that dural repair was promoted by
damage to the pia arachnoid, the underlying brain and the
presence of blood clot. It is therefore possible that a spinal
needle carefully placed in the subarachnoid space does not
promote dural healing, as trauma to adjacent tissue is
minimal. Indeed, the observation that blood promotes dural
healing agrees with Gormley's original observation that
bloody taps were less likely to lead to a post-dural puncture
headache as a consequence of a persistence CSF leak.
51
Needle tip deformation and dural perforation
It has been proposed that contact with bone during insertion
may lead to spinal needle tip deformation.
67 90
Damaged
needle tips could lead to an increase in the size of the
subsequent dural perforation. Recent in vivo studies have
demonstrated that the cutting type spinal needle is more
likely to be deformed after bony contact than comparable
sized pencil-point needles.
90
However, no in vivo
67
or
in vitro work has yet demonstrated an increase in the size of
dural perforation where damaged needles are used.
Consequences of dural puncture
Puncture of the dura has the potential to allow the
development of excessive leakage of CSF. Excess loss of
CSF leads to intracranial hypotension and a demonstrable
reduction in CSF volume.
52
After the development of post-
dural puncture headache, the presence of a CSF leak has
been con®rmed with radionuclide cisternography,
100
Post-dural puncture headache
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radionuclide myelography, manometric studies, epiduro-
scopy and direct visualization at laminectomy. The adult
subarachnoid pressure of 5±15 cm H
2
0 is reduced to
4.0 cm H
2
0 or less.
100
The rate of CSF loss through the dural
perforation
29
(0.084±4.5 ml s
±1
) is generally greater than the
rate of CSF production (0.35 ml min
±1
), particularly with
needle sizes larger than 25G.
29 101
Gadolinium-enhanced MRI, in the presence of a post-
dural puncture headache, frequently demonstrates `sagging'
of the intracranial structures. The MRI may or may not
demonstrate meningeal enhancement.
56
The meningeal
enhancement is attributable to vasodilatation of thin-walled
vessels in response to the intracranial hypotension.
Histological studies have con®rmed that the vasodilation
of meningeal vessels is unrelated to an in¯ammatory
response.
56
Although the loss of CSF and lowering of CSF pressure is
not disputed, the actual mechanism producing the headache
is unclear. There are two possible explanations. First, the
lowering of CSF pressure causes traction on the intracranial
structures in the upright position. These structures are pain
sensitive, leading to the characteristic headache. Secondly,
the loss of CSF produces a compensatory venodilatation
vis-a
Á-vis the Monro±Kellie doctrine.
52
The Monro±Kellie
doctrine, or hypothesis, states that the sum of volumes of the
brain, CSF, and intracranial blood is constant. The conse-
quence of a decrease in CSF volume is a compensatory
increase in blood volume. The venodilatation is then
responsible for the headache.
Incidence
The incidence of post-dural puncture headache was 66% in
1898.
137
This alarmingly high incidence of post-spinal
headache was likely attributable to the use of large gauge,
medium bevel, cutting spinal needles (needles 5, 6 and 7,
Fig. 1). In 1956, with the introduction of 22G and 24G
needles, the incidence was estimated to be 11%.
132
Today the use of ®ne gauge pencil-point needles, such as
the Whitacre and Sprotte
â
has produced a greater reduction
in the incidence of post-dural puncture headache, which
varies with the type of procedure and patients involved. It is
related to the size and design of the spinal needle used
(Fig. 1; Table 1),
36
the experience of the personnel
performing the dural puncture,
35
and the age and sex of
the patient.
Spinal anaesthesia
Anaesthetists have been active in attempting to reduce the
incidence of post-spinal headache. Reducing the size of the
spinal needle has made a signi®cant impact on the incidence
of post-spinal headache. The incidence is ~40% with a
22G needle; 25% with a 25G needle;
444
2%±12% with
a 26G Quincke needle;
445
and <2% with a 29G needle.
47
However, technical dif®culties leading to failure of the
spinal anaesthetic are common with needles of 29G or
smaller.
47
In 1951, Whitacre and Hart
59
introduced the
`atraumatic' spinal needle (needle 3, Fig. 1). This design
offered the handling characteristics of larger needles with a
low incidence of post-spinal headache (Table 1). Needle
modi®cations since that time, such as the Sprotte
â119
and
Atraucan
â63
needles, promise further reductions in post-
spinal headache.
Diagnostic lumbar puncture
The acceptance of small gauge needles for diagnostic
lumbar puncture has been slow to develop. Until recently,
Fig 1 Graphical representations of epidural (needle 4) and spinal needle
tip design. Note the large ori®ce and conical tip of the Sprotte
â
Needle
2, compared with the small ori®ce and diamond tip of the Whitacre
Needle 3. Needles 5, 6 and 7 were provided by the Shef®eld Anaesthetic
Museum and are an indication of the style of spinal needles used in the
past. 1, 26G Atraucan
â
Double Bevel Design; 2, 26G Sprotte
â
Style
Pencil Point; 3, 22G Whitacre Style Pencil Point; 4, 16G Tuohy Needle;
5, 17G Barkers Spinal Needle; 6, Large Gauge Spinal Needle; 7, 18G
Crawford Needle.
Table 1 Relationship between needle size and incidence of post-dural
puncture headache
Needle tip
design
Needle
gauge
Incidence of post-dural
puncture headache (%)
Quincke 22 36
128
Quincke 25 3±25
47
Quincke 26 0.3±20
45 107
Quincke 27 1.5±5.6
25 69
Quincke 29 0±2
45 47 69
Quincke 32 0.4
46
Sprotte 24 0±9.6
13 107
Whitacre 20 2±5
17
Whitacre 22 0.63±4
17 112
Whitacre 25 0±14.5
13 98
Whitacre 27 0
25
Atraucan 26 2.5±4
115 131
Tuohy 16 70
26
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diagnostic lumbar puncture was commonly performed with
a 20G or even 18G medium bevel cutting needle with a high
incidence of post-spinal headache. A recent publication
promoted the virtues of a 20G needle for reducing the
incidence of dural puncture headache!
125
Though anaes-
thetists are in general critical of the use of large gauge
needles for lumbar puncture,
105
neurologists maintain that
adequate ¯ow of CSF can only be achieved with spinal
needles of 22G or greater.
18
Obstetrics
The parturient is at particular risk of dural puncture and the
subsequent headache because of their sex, young age, and
the widespread application of epidural anaesthesia.
44
In
parturients receiving epidural anaesthesia, the incidence of
dural puncture is between 0 and 2.6%.
104
The incidence is
inversely related to the experience of the anaesthetist,
80
and
is said to be reduced by orientation of the needle bevel
parallel to the dural ®bres.
87
Loss of resistance to air confers
a higher risk of dural puncture than loss of resistance to
¯uid.
105
After a dural puncture with a 16G Tuohy needle, up
to 70% of subjects will report symptoms related to low CSF
pressure.
26
Despite the high incidence of headache con-
sequent upon dural puncture with a Tuohy needle, the
anaesthetist needs to consider a differential diagnosis, as
intracranial haematoma,
65
or tumour
38
presenting with
similar symptoms to, or in association with, a post-dural
puncture headache have been described.
In the presence of a known dural puncture, it is often
recommended that pushing in the second stage should be
avoided.
88
The evidence to support this assertion is far from
conclusive, and anger from the parturient about the
medicalization of her labour is best avoided.
26 133
Children
Post-dural puncture headache is reported as uncommon in
children.
14
Although low CSF pressure or other physio-
logical differences have been proffered as reasons to explain
the low incidence in children, it is likely that a low reporting
rate is the explanation. Groups that have explored the
incidence of post-spinal headaches in children have found
rates comparable to young adults.
73
Prevention
Spinal needles have undergone numerous modi®cations in
recent years, the aim being to reduce the incidence of dural
puncture headache. The principal factor responsible for the
development of a dural puncture headache is the size of
the dural perforation. Other factors such as the shape of the
dural perforation and the orientation of the spinal needle
have a less signi®cant role.
Needle size
Large spinal needles will clearly produce large dural
perforations where the likelihood of a dural puncture
headache is high. Conversely, the smaller needles produce
small dural perforations with a lower incidence of headache.
Fine gauge spinal needles, 29G or smaller, are technically
more dif®cult to use,
64
and for spinal anaesthesia at least,
are associated with a high failure rate.
45
A balance has to be
struck between the risks of dural puncture headache and
technical failure. 25G, 26G and 27G
69
needles probably
represent the optimum needle size for spinal anaesthesia.
Neurologists argue that for the purposes of aspiration of
CSF and measurement of CSF pressure, 22G needles are the
smallest practical needles.
Needle orientation
There are many clinical,
79 87
and laboratory,
36 101
studies that
lend credence to the hypothesis that perpendicular orient-
ation of the bevel of a spinal or epidural needle leads to a
reduction in the incidence of post-dural puncture headache.
Needle design
Over the years since Quincke and Bier, a large number of
needle designs have been introduced. The Quincke type is
the standard needle with a medium cutting bevel and the
ori®ce at the needle tip (needle 7, Fig. 1). In 1926, Greene
53
proposed a needle tip design with a non-cutting edge that
would separate the dural ®bres to avoid post-dural puncture
headache. In 1951, the Whitacre needle was introduced and,
in 1987, the Sprotte needle. The generic term for these
needles is pencil-point or atraumatic, though in truth they
are neither. The Whitacre needle (needle 3, Fig. 1) has a
diamond shaped tip, and the Sprotte needle (needle 2, Fig. 1)
tip is conical. The ori®ce is up to 0.5 mm from the needle
tip. Clinical and laboratory
29
studies have con®rmed that
pencil-point needles produce fewer post-dural puncture
headaches than medium bevel cutting needles. However,
there are disadvantages. Paraesthesia has been observed
with the pencil-point needles.
115
The reason may lie in the
distance from the tip of the needle to the ori®ce. The tip has
to be passed at least 0.5 mm into the subarachnoid space
before the ori®ce enters the subarachnoid space. The tip then
has the opportunity to impinge upon the stretched cauda
equina. Giving credence to this hypothesis, paraesthesia is
uncommon with the short bevel needles or the Atraucan
â
needle.
115
The problem of low CSF ¯ow and paraesthesia seen with
the pencil-point needles has promoted the search for novel
needle designs. The Atraucan
â
(needle 1, Fig. 1) has
recently been marketed. It has an ori®ce at the tip of the
needle. The Atraucan
â
has a narrow cutting tip and an
atraumatic bevel. Initial reports of these needles are
promising as regards ease of use and low dural puncture
headache rate.
115
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Operator skill level and fatigue
It has been suggested that the incidence of inadvertent dural
puncture during epidural anaesthesia is inversely related to
operator experience.
104
However, sleep deprivation, oper-
ator fatigue and the effect of night work may be a
confounding variable producing the higher incidence of
inadvertent dural puncture in junior personnel performing
epidural analgesia.
Presentation of dural puncture headache
Onset
Headache and backache are the dominant symptoms that
develop after accidental dural puncture. Ninety per cent of
headaches will occur within 3 days of the procedure,
104
and
66% start within the ®rst 48 h.
76
Rarely, the headache
develops between 5 and 14 days after the procedure.
Headache may present immediately after dural puncture.
133
However, this is rare, and its occurrence should alert the
physician to alternative causes.
Symptoms
Headache is the predominant, but not ubiquitous presenting
complaint.
83
The headache is described as severe, `searing
and spreading like hot metal'.
133
The common distribution
is over the frontal and occipital areas radiating to the neck
and shoulders. The temporal, vertex and nuchal areas are
reported less commonly as the site of discomfort, although
neck stiffness may be present. The pain is exacerbated by
head movement, and adoption of the upright posture, and
relieved by lying down. An increase in severity of the
headache on standing is the sine qua non of post-dural
puncture headache.
Other symptoms associated with dural puncture headache
include nausea, vomiting, hearing loss,
78
tinnitus, vertigo,
dizziness and paraesthesia of the scalp, and upper
108
and
lower limb pain. Visual disturbances such as diplopia or
cortical blindness have been reported.
132
Cranial nerve
palsies are not uncommon.
16
Two cases of thoracic back
pain without headache have been described.
37
Neurological
symptoms may precede the onset of grand mal seizures.
Intracranial subdural haematomas, cerebral herniation and
death,
39
have been described as a consequence of dural
puncture. Unless a headache with postural features is
present, the diagnosis of post-dural puncture headache
should be questioned, as other serious intracranial causes for
headache must be excluded.
3
Diagnosis
The history of accidental or deliberate dural puncture and
symptoms of a postural headache, neck ache and the
presence of neurological signs, usually guide the diagnosis.
Where there is doubt regarding the diagnosis of post-dural
puncture headache, additional tests may con®rm the clinical
®ndings. A diagnostic lumbar puncture may demonstrate a
low CSF opening pressure or a `dry tap', a slightly raised
CSF protein, and a rise in CSF lymphocyte count. An MRI
may demonstrate: diffuse dural enhancement, with evidence
of a sagging brain; descent of the brain, optic chiasm, and
brain stem; obliteration of the basilar cisterns; and enlarge-
ment of the pituitary gland.
85
CT myelography, retrograde
radionuclide myelography, cisternography, or thin section
MRI
130
can be used to locate the spinal source of the CSF
leak.
Differential diagnosis
The diagnosis of post-dural puncture headache is frequently
clear from the history of dural puncture and the presence of
a severe postural headache. However, it is important to
consider alternative diagnoses (Table 2) as serious intra-
cranial pathology may masquerade as a post-dural puncture
headache. Clinicians should remember that intracranial
hypotension can lead to intracranial haemorrhage
through tearing of bridging dural veins,
65 94
and a delay in
diagnosis and treatment can be dangerous. Diagnoses that
may masquerade as post-dural puncture headache include
intracranial tumours,
338
intracranial haematoma,
32 40
pituit-
ary apoplexy,
77
cerebral venous thrombosis,
122 134
migraine, chemical or infective meningitis,
106
and non-
speci®c headache. It has been estimated that 39% of
parturients report symptoms of a headache unrelated to
dural puncture following delivery.
120
Duration
The largest follow-up of post-dural puncture headache is
still that of Vandam and Dripps in 1956.
132
They reported
that 72% of headaches resolved within 7 days, and 87% had
resolved in 6 months (Table 3). The duration of the
headache has remained unchanged since that reported in
1956.
26
In a minority of patients the headache can persist.
133
Indeed, case reports have described the persistence of
headache for as long as 1±8 yr after dural puncture.
80
It is
interesting to note that even post-dural puncture headaches
of this duration have been successfully treated with an
epidural blood patch.
72
Table 2 Differential diagnosis of post-dural puncture headache
Viral, chemical or bacterial meningitis
106
Intracranial haemorrhage
65 94 104
Cerebral venous thrombosis
10
Intracranial tumour
338
Non-speci®c headache
44
Pituitary apoplexy
77
Cerebral infarction
Uncal herniation
39 97
Sinus headache
Migraine
76
Drugs (e.g. caffeine, amphetamine)
Pre-eclampsia
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Treatment
Overview
The literature regarding the treatment of post-dural puncture
headache often involves small numbers of patients, or uses
inappropriate statistical analysis. Studies observing the
effects of treatments in post-dural puncture headache often
fail to recognize that, with no treatment, over 85% of post-
dural puncture headaches will resolve within 6 weeks
(Table 3).
Psychological
Patients who develop post-dural puncture headache may
reveal a wide range of emotional responses from misery and
tears to anger and panic. It is important both from a clinical
and medico-legal point of view, to discuss the possibility of
headache before a procedure is undertaken that has a risk of
this complication. Even so, this discussion will not prepare
the patient for the sensations he or she feels should the
headache develop.
133
Obstetric patients are particularly
unfortunate should they develop this complication, as they
expect to feel well and happy and to be able to look after
their new baby. It is important to give the mother a thorough
explanation of the reason for the headache, the expected
time course, and the therapeutic options available. Regular
review is essential to monitor the course and therapeutic
manoeuvres undertaken.
Simple
Bed rest has been shown to be of no bene®t.
118
Supportive
therapy such as rehydration, acetaminophen, non-steroidal
anti-in¯ammatory drugs, opioids, and antiemetics may
control the symptoms and so reduce the need for more
aggressive therapy,
89
but do not provide complete relief.
44
Posture
If a patient develops a headache, they should be encouraged
to lie in a comfortable position. The patient will often have
identi®ed this, without the intervention of an anaesthetist.
There is no clinical evidence to support the maintenance of
the supine position before or after the onset of the headache
as a means of treatment.
68
The prone position has been
advocated, but it is not a comfortable position for the
post-partum patient. The prone position raises the intra-
abdominal pressure, which is transmitted to the epidural
space and may alleviate the headache. A clinical trial of the
prone position following dural puncture failed to demon-
strate a reduction in post-dural puncture headache.
55
Abdominal binder
A tight abdominal binder raises the intra-abdominal pres-
sure. The elevated intra-abdominal pressure is transmitted
to the epidural space and may relieve the headache.
Unfortunately, tight binders are uncomfortable and are
seldom used in current practice. There are few units that
would recommend this approach.
86
Pharmacological treatment
The aim of management of post-dural puncture headache is
to: (i) replace the lost CSF; (ii) seal the puncture site; and
(iii) control the cerebral vasodilatation.
A number of therapeutic agents have been suggested for
the management of post-dural puncture headache. The main
problem in choosing the most appropriate one is the lack of
large, randomized, controlled clinical trials.
DDAVP, ACTH
A report in 1964 identi®ed 49 methods for treating post-
spinal headache.
127
There appears to be no limit to the
imagination of physicians in treatments offered for post-
spinal headache. However, there is a lack of statistical data
to support their ideas. Regarding DDAVP (desmopressin
acetate), intramuscular administration before lumbar punc-
ture was not shown to reduce the incidence of post-dural
puncture headache.
57
ACTH (adrenocorticotrophic
hor-
mone)
21
has been administered as an infusion (1.5 mgkg
±1
),
but inadequate statistical analysis prevents assessment of the
value of ACTH.
Caffeine
Caffeine is a central nervous system stimulant that amongst
other properties produces cerebral vasoconstriction. I.V.
caffeine 0.5 g was recommended as a treatment of post-
dural puncture headache in 1944.
62
It is available in an oral
and i.v. form. The oral form is well absorbed with peak
levels reached in 30 min. Caffeine crosses the blood±brain
barrier and the long half-life of 3±7.5 h allows for infrequent
dosing schedules.
The most frequently quoted work on the treatment of
post-dural puncture headache with caffeine is that of
Sechzer.
113 114
He evaluated the effects of one or two 0.5 g
doses of i.v. caffeine on subjects with established post-dural
puncture headache. There are some statistical and methodo-
logical ¯aws in this study, but it was concluded that i.v.
Table 3 Estimated rate of spontaneous recovery from post-dural puncture
headache
26 80 132
Duration (days) Percentage recovery
1±2 24
3±4 29
5±7 19
8±14 8
3±6 weeks 5
3±6 months 2
7±12 months 4
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caffeine is an effective therapy for post-dural puncture
headache.
Dose
The dose now recommended for the treatment of post-dural
puncture headache is 300±500 mg of oral or i.v. caffeine
once or twice daily.
12 66
One cup of coffee contains about
50±100 mg of caffeine and soft drinks contain 35±50 mg.
The LD
50
for caffeine is of the order of 150 mg kg
±1
.
However, therapeutic doses have been associated with
central nervous system toxicity,
9
and atrial ®brillation.
Mode of action
It is assumed that caffeine acts through vasoconstriction of
dilated cerebral vessels.
12
If cerebral vasodilatation were the
source of the pain, cerebral vasoconstriction might limit the
pain experienced. Indeed, it has been demonstrated that
caffeine causes a reduction in cerebral blood ¯ow,
116
but
this effect is not sustained. Caffeine therapy is simple to
administer compared with the technical skills required to
perform an epidural blood patch. Were caffeine as success-
ful as suggested by previous reports, it would no doubt be
widely advocated. However, a North American hospital
survey of the treatment of post-dural puncture headache
identi®ed that most hospital practitioners had abandoned the
use of caffeine as they had found it ineffective.
8
The effects
of caffeine on post-dural puncture headache seem, at
best, temporary.
12
In addition, caffeine is not a therapy
without complications,
9
and does not restore normal CSF
dynamics, thus leaving the patient at risk from the serious
complications associated with low CSF pressure.
Sumatriptan
The treatment for migranous headaches has focused on
modi®cation of cerebral vascular tone. Sumatriptan is a
5-HT
1D
receptor agonist that promotes cerebral vasocon-
striction, in a similar way to caffeine.
123
Sumatriptan is
advocated for the management of migraine and recently, for
post-dural puncture headache. There have been only a few
case reports where sumatriptan was used successfully to
manage post-dural puncture headache.
61
However, a recent
controlled trial found no evidence of bene®t from
Sumatriptan for the conservative management of post-
dural puncture headache.
23
Epidural blood patch
History
After the observation that `bloody taps' were associated
with a reduced headache rate,
51
the concept of the epidural
blood patch has developed. The theory is that the blood,
once introduced into the epidural space, will clot and
occlude the perforation, preventing further CSF leak. The
high success rate and the low incidence of complications
have established the epidural blood patch as the standard
against which to evaluate alternative methods to treat post-
dural puncture headache.
Technique
The presence of fever, infection on the back, coagulopathy,
or patient refusal are contraindications to the performance
of an epidural blood patch.
1
As a precautionary measure, a
sample of the subject's blood should be sent to micro-
biology for culture.
27
With the patient in the lateral position,
the epidural space is located with a Tuohy needle at the level
of the supposed dural puncture or an intervertertebral space
lower. The operator should be prepared for the presence of
CSF within the epidural space. Up to 30 ml of blood is then
taken from the patient's arm and injecting slowly through
the Tuohy needle. Should the patient describe lancinating
pain of dermatomal origin the procedure must be stopped.
27
There is no consensus as to the precise volume of blood
required. Most practitioners now recognise that the 2±3 ml
of blood originally described by Gormley is inadequate, and
that 20±30 ml of blood is more likely to guarantee success.
27
Larger volumes, up to 60 ml,
97
have been used successfully
in cases of spontaneous intracranial hypotension. At the
conclusion of the procedure, the patient is asked to lie still
for one
133
or, preferably, 2 h,
81
and is then allowed to walk.
Contraindications
Contraindications include those that normally apply to
epidurals, but include a raised white cell count, pyrexia and
technical dif®culties. Limited experience with HIV-positive
patients suggest that it is acceptable providing no other
bacterial or viral illnesses are active.
126
Epidural blood
patch following diagnostic lumbar puncture in the oncology
patient raises the potential for seeding the neuroaxis with
neoplastic cells. One case has been reported of a successful
patch without complications,
109
and one case
11
where the
risks of central nervous system (CNS) seeding of leukaemia
were considered to outweigh the bene®ts of an epidural
blood patch.
The blood patch
Using either radiolabelled red cells
124
or an MRI scan,
7
several studies have reported the degree of spread of the
epidural blood patch. After injection, blood is distributed
caudally and cephalad regardless of the direction of the
bevel of the Tuohy needle. The blood also passes
circumferentially around to the anterior epidural space.
The thecal space is compressed and displaced by the blood.
In addition, the blood passes out of the intervertebral
foramina and into the paravertebral space. The mean spread
of 14 ml of blood is six spinal segments cephalad and three
segments caudad. Compression of the thecal space for the
®rst 3 h, and a presumed elevation of subarachnoid pressure,
may explain the rapid resolution of the headache.
Compression of the thecal sac is not, however, sustained
and maintenance of the therapeutic effect is likely to be
attributable to the presence of the clot eliminating the CSF
leak. It has been observed that CSF acts as a procoagulant,
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accelerating the clotting process.
24
At 7±13 h, there is clot
resolution leaving a thick layer of mature clot over the
dorsal part of the thecal sac. Animal studies have demon-
strated that 7 days after the administration of an epidural
blood patch, there is widespread ®broblastic activity and
collagen formation.
34 74
Fortunately, the presence of blood
does not initiate an in¯ammatory process and there is no
evidence of axonal oedema, necrosis or demyelination.
Outcome
The technique has a success rate of 70±98% if carried out
more than 24 h after the dural puncture.
1
If an epidural blood
patch fails to resolve the headache, repeating the blood
patch has a similar success rate. Failure of the second patch
and repeating the patch for a third or fourth time has been
reported. However, in the presence of persistent severe
headache, an alternative cause should be considered.
Complications
Immediate exacerbation of symptoms and radicular pain
have been described.
136
These symptoms do not persist and
resolve with the administration of simple painkillers. Long-
term complications of epidural blood patch are rare. A
single case report of an inadvertent subdural epidural blood
patch described non-postural, persistent headache and lower
extremity discomfort.
103
The issue of the effect of the blood patch on the success of
subsequent epidurals has been addressed.
260
Though case
reports describe limited spread of epidural analgesia
99
after
previous epidural blood patch, a large retrospective study
over a 12-yr period
60
found that subsequent epidural
analgesia was successful in >96% of patients.
Prophylactic epidural blood patch
Where the known incidence of post-dural puncture head-
ache is high, such as in the parturient, the use of a
prophylactic epidural blood patch after accidental dural
puncture, that is blood patching before the onset of
symptoms, is an attractive option. Prophylactic patching
has generally been dismissed as ineffective, but the
evidence is con¯icting. A controlled trial in post-myelogram
headaches,
54
and one after spinal anaesthesia and after
unintentional dural puncture with an epidural needle,
22
have
con®rmed the bene®t of prophylactic patching. Those
studies that have not supported the use of prophylactic
patching may have used insuf®cient blood for the patch.
22
The pressure gradient between the thecal and epidural space
may be high immediately after dural puncture and lead to
patch separation from the site of the perforation. Blood
patching at that time may therefore need a greater volume of
blood to produce a successful patch compared with a late
patch, where the CSF pressure may be lower.
Chronic headache
Patients may present with features of a post-spinal headache
never having received an epidural or spinal injection. A
report of six such cases, with headaches that had been
present between 1 and 20 yr, showed complete relief of
headache following lumbar epidural blood patch.
91
It is
interesting to speculate that these headaches may have
been attributable to unidenti®ed spontaneous intracranial
hypotension.
Epidural saline
Concerns have been expressed about the potential danger of
an autologous epidural blood patch for the treatment of post-
dural puncture headache. The immediate resolution of the
headache with a blood patch is attributable to thecal
compression raising the CSF pressure. An epidural injection
of saline would, in theory, produce the same mass effect,
and restore normal CSF dynamics. As saline is a relatively
inert and sterile solution, epidural saline bolus or infusion
appears to be an attractive alternative. Regimens that have
been advocated include: (i) 1.0±1.5 litre of epidural
Hartmanns solution over 24 h, starting on the ®rst day
after dural puncture;
28 84 121
(ii) up to 35 ml h
±1
of epidural
saline or Hartmanns solution for 24±48 h, or after develop-
ment of the headache; (iii) a single 30 ml bolus of epidural
saline after development of headache;
584
and (iv) 10±120 ml
of saline injected as a bolus via the caudal epidural
space.
6 129
Advocates of an epidural saline bolus or infusion
maintain that the lumbar injection of saline raises epidural
and intrathecal pressure. Reduction in the leak would allow
the dura to repair. However, observations of the pressures
produced in the subarachnoid and epidural space show that,
despite a large rise in epidural pressure, the consequent rise
in subarachnoid pressure maintains the differential pressure
across the dura. The pressure rise is also not sustained and is
dissipated within 10 min.
129
The saline may induce an
in¯ammatory reaction within the epidural space, promoting
closure of the dural perforation. Histological studies have
not demonstrated an in¯ammatory response following
epidural Dextran 40 administration, however, in contrast
to an autologous blood patch.
74
There is no reason to
suppose that epidural saline is more likely to accelerate
dural healing through a proin¯ammatory action than
Dextran 40. Thus, there are no studies that are able to
demonstrate either a sustained rise in CSF pressure or
accelerated closure of the dural perforation after the
administration of epidural saline. Whilst there are many
case reports describing the success of epidural saline,
comparative trials with epidural blood patches have not
demonstrated the long-term ef®cacy of epidural saline
placement.
5
It is dif®cult to conclude from the evidence
therefore, that epidural saline administration will restore
normal CSF dynamics. The administration of large volumes
of epidural saline may result in intraocular haemorrhages
through a precipitous rise in intracranial pressure.
19
Epidural dextran
Despite the paucity of evidence to support epidural saline,
some observers have considered the epidural administration
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of Dextran 40.
117
Those studies that recommend Dextran 40,
either as an infusion or as a bolus, conclude that the high
molecular weight and viscosity of Dextran 40 slows its
removal from the epidural space. The sustained tamponade
around the dural perforation allows spontaneous closure.
However, it is unlikely that Dextran 40 will act any
differently to saline in the epidural space. Any pressure rise
within the subarachnoid space would, like saline, be only
transient. Histological inspection of the epidural space after
administration of Dextran 40,
74
does not demonstrate any
in¯ammatory response that would promote the healing
process. The evidence for the administration of epidural
Dextran to treat post-dural puncture headache is not proven
and the theoretical argument to justify its use is poor.
Epidural, intrathecal and parenteral opioids
A number of authors have advocated the use of epidural,
42
intrathecal
20
or parenteral morphine;
41
the majority of these
reports are either case reports or inadequately controlled
trials. Some of the studies used epidural morphine after the
onset of headache, others used epidural or intrathecal
morphine as prophylaxis or in combination with an
intrathecal catheter.
20
A controlled trial of intrathecal
fentanyl as prophylaxis found no evidence of a reduction
in the incidence of post-spinal headache after dural puncture
with a 25-gauge spinal needle.
31
Fibrin glue
Alternative agents to blood, such as ®brinous glue, have
been proposed to repair spinal dural perforations.
48
Cranial
dural perforations are frequently repaired successfully with
it. In the case of lumbar dural perforation, the ®brin glue
may be placed blindly or using CT-guided percutaneous
injection.
92
There is, however, a risk of the development of
aseptic meningitis with this procedure.
111
In addition,
manufacturers have recently warned against the application
of some types of tissue glue where it may be exposed to
nervous tissue.
110
Intrathecal catheters
After accidental dural perforation with a Tuohy needle, it
has been suggested that placement of a spinal catheter
through the perforation may provoke an in¯ammatory
reaction that will seal the hole. Evidence to support this
claim is con¯icting.
30 135
The mean age of the patients in
some of the trials has been >50 yr, where the rate of post-
dural puncture headache is low. Some trials have used spinal
microcatheters, 26G±32G; others have placed 20G epidural
catheters through an 18G Tuohy needle.
Histopathological studies in animals and humans with
long-term intrathecal catheters con®rm the presence of
an in¯ammatory reaction at the site of the catheter.
Comparison between the effects of a catheter left in situ
for 24 h and for several days or weeks would seem
inappropriate.
96
If, after accidental dural puncture with a
Tuohy needle, the insertion of an intrathecal catheter
reduced the post-dural puncture headache rate, then it
would be worth considering. However, neurological com-
plications, such as cauda equina syndrome and infection,
should preclude the use of intrathecal catheters.
Surgery
There are case reports of persistent CSF leaks, that are
unresponsive to other therapies, being treated successfully
by surgical closure of the dural perforation.
58
This is clearly
a last resort treatment.
Conclusions
Post-dural puncture headache is a complication that should
not to be treated lightly. There is the potential for
considerable morbidity,
10
even death.
39 104
In the majority
of cases, the problem will resolve spontaneously. In some
patients, the headache lasts for months or even years.
Therapies that have been offered have not always arisen
through the application of logic or reasoning. Gormley's
observation that bloody taps were less likely to give rise to
headaches, though probably incorrect,
71
has led to the
widespread application of blood patching for the treatment
of post-dural puncture headache. The bene®t of prophylactic
blood patching is not so clear but deserves consideration in
those most at risk from a headache, such as the parturient,
and after accidental dural perforation with a Tuohy needle.
There are occasions when blood patches appear to be
ineffective in treating the headache. It is wise to consider
other causes of the headache before applying alternative
therapeutic options. Surgical closure of the dural tear is an
option of last resort.
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