Focus On: Post-Dural Puncture Headache

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ACEP News
August 2007

By Brad Younggren, MD and Emily Merchant, MD

 

It has been known for some time that lumbar punctures may result in a headache. How ironic, then, that physicians in the emergency department are often performing this procedure for evaluation of just that symptom: headache. These patients will often present again to the emergency department complaining of headache, and thus emergency physicians must be able to recognize and treat this procedural complication.

How is post-dural puncture headache (PDPH) defined? It is a headache that improves when the patient is supine and worsens with sitting upright. Its onset is after a lumbar puncture, and most occur within the first 3 days following the procedure.1,2,3 It is not a benign complication, with reports of subdural hematoma4,5 and seizures following dural puncture.

The first dural puncture was performed in 1891 by Quincke. August Bier reported the first case of PDPH in 1898. He actually suffered from this and proposed that the headache was caused by leakage of cerebrospinal fluid (CSF) through the dural puncture site.

A patient with a PDPH usually complains of a throbbing or dull pain in a frontal-occipital distribution. However, this pain can later generalize, and some patients may experience radiation of the pain into the interscapular region. As noted, the pain is worsened with the upright position and improved with lying down. Any movements that increase intracranial pressure (such as coughing, sneezing, straining, or ocular compression) may exacerbate symptoms. Visual changes, photophobia, and auditory changes, including tinnitus, are not uncommon.6

Signs that may be found on physical examination of the patient include the Gutsche sign: the application of firm manual pressure around the abdomen of the seated patient produces transient relief. Nuchal rigidity may also be seen. Other patients may have a cranial nerve palsy inducing diplopia.

When a patient returns to the ED still complaining of headache, the differential diagnosis should be re-evaluated, and the physician should not assume that the patient has a PDPH. Meningitis, central venous sinus thrombosis (CVST), spinal hematoma, cortical/cerebral vein thrombosis, intracranial subdural hematoma, benign intracranial hypertension, migraine, and caffeine-withdrawal headache should all be considered.

Some authors have suggested that the intracranial hypotension resulting from a dural leak might predispose to CVST, especially in a patient with hereditary prothrombotic conditions, mainly because the hypotension leads to venous dilation and blood stasis. Also, in those with prothrombotic conditions, cortical/cerebral vein thrombosis must be considered.7,8 For patients with hypocoagulable states, the possibility of spinal hematoma, which may cause transient or permanent paraparesis, should be considered.

Although it is not disputed that loss of CSF decreases the CSF pressure, it is unclear as to the exact mechanism of the headache. Bier first hypothesized that continued leakage leads to the pain, and this idea later developed into the traction theory proposed by Kunkle in 1943: lower CSF pressure results in the sagging of the brain and meninges, thus causing traction on pain-sensitive structures. 9

Another theory, the vascular theory, suggests that loss of CSF activates adenosine receptors directly, causing compensatory dilation of cerebral veins and venous sinuses, resulting in stretching of pain-sensitive fibers in the cerebrum.3

How common are these headaches? In the literature, incidences ranging from 5% to 30% have been reported.3,10 Obstetrical patients tend to have a greater incidence of post-dural puncture headaches, which is most likely caused by the larger size of the needle used for epidural anesthesia. Most of these are the result of epidurals that are accidentally converted to spinal cases. The numbers are probably different for patients subjected to LP in the emergency department. The incidence of PDPH following an ED lumbar puncture appears to be in the range of 5% to 10%.

A few factors appear to increase a patient's risk of developing a post-dural puncture headache. Female gender, pregnancy, younger age (20-40 years old), and history of headache prior to the lumbar puncture increase the likelihood of developing PDPH.11,12 It has been speculated that the dura mater of the elderly is less stretchable.

Although in the past, operator experience and amount of fluid removed were assumed to be related to the PDPH, in a series of 501 patients as well as a meta-analysis, neither was found to be significant.3,11 Also, making the patient lie in the recumbent position for 30 minutes after LP is common practice, but this has not been shown to be effective in preventing PDPH.12

Needle factors--such as size, position of the bevel, and shape of the tip--have been shown to affect the incidence of PDPH. A smaller bore (higher gauge) has been associated with a decreased incidence of headaches, as well as decreased incidence of hearing impairment.13

In the two largest studies of PDPH in obstetric patients, smaller needle bore was directly correlated with a significant decrease in the incidence of PDPH.14,15 In addition, a longitudinal orientation of the bevel tip is associated with a lower incidence of PDPH.16

The two shapes of needle tip that are used are the cutting needle (Quincke, Atraucan) and the pencil point (Sprotte, GM, Whitacre). The pencil point needle tip has been associated with lower incidence of PDPH. In a recent randomized trial, the incidence of PDPH was 36% in the cutting needle group and 3% in the Whitacre needle group.17

Interestingly, electron microscopy shows that the pencil point tip actually causes more trauma, which raises the question of why the incidence of PDPH is lower in these patients. It is theorized that this increased localized trauma might initiate an inflammatory reaction that promotes healing at the puncture site. Many emergency departments still use the cutting needles, possibly because the pencil point needles require more expertise to use and may be associated with a higher failure rate.

Do any methods exist to prevent PDPH? Neither lying supine nor bed rest following the procedure has been shown to reduce the frequency of PDPH. Prophylactic epidural blood patch (EBP) is controversial. A recent randomized, double-blind study found that this did not significantly reduce the incidence of PDPH.18 Intrathecal morphine has not been shown to be of any benefit.

How do we treat these headaches? Medical therapy is the mainstay of treatment. Most of these headaches will be mild in nature, lasting less than 24 hours. Oral analgesics, including opiates, are appropriate for these patients. In those with moderate to severe headaches, intravenous fluids, caffeine, anti-emetics, and IV opiates should be considered.

Caffeine has been reported to be between 70% and 80% effective at relieving post-dural puncture headaches. The most common mode of administration is 500 mg in 1 L normal saline, delivered intravenously over 1 hour. It should be avoided, though, in some patients, specifically those with pre-existing vasoconstriction such as pre-eclampsia. Reported side effects of this therapy include seizures as well as atrial fibrillation. The success of caffeine treatment supports the vascular theory of PDPH, as it inhibits adenosine receptors and therefore acts as a cerebral vasoconstrictor.

Cosyntropin is an adrenocorticotropic hormone (ACTH) analog that is less antigenic than the naturally occurring hormone. Several case reports have described cosyntropin administration for the treatment of PDPH.19,20 Cosyntropin stimulates the adrenal cortex to secrete glucocorticoids, mineralocorticoids, and weak androgens; it activates adenyl cyclase, with a resultant increase in intracellular cAMP. It has been speculated that it increases CSF production through a sodium active transport mechanism, as well as possibly increasing beta-endorphins in the CNS, with a subsequent increase in the pain threshold. The dose is 0.25-0.75 mg IV. Side effects include mood elevation and anti-inflammatory effects.

In a study comparing cosyntropin therapy to caffeine therapy, rates for successful treatment without need for rescue therapy were 56% and 80%, respectively. This was done with a sample size of nearly 40 patients, which left the study underpowered. The confidence intervals were very large, suggesting that the appropriate conclusion is probably that both caffeine and cosyntropin may have a role in relieving PDPH but that there wasn't a statistically significant difference between the two therapies.21 It has been suggested that perhaps an initial combination of both pharmacotherapies would be the best course of action preceding blood patch.

When medical therapies fail for relief of PDPH, management should move on to procedural therapies. The most common procedural therapy used for PDPH is an epidural blood patch (EBP). Less common therapies reported include epidural fibrin glue, epidural crystalloid/colloid infusion, caudal saline infusion, and surgery.

Epidural blood patch is assumed to work by increasing CSF pressure and stimulating fibrin and platelet formation. The amount of blood currently used in an EBP is controversial. Suggested amounts range from 2 mL to 20 mL, with more recent recommendations to use a larger amount.22 Success rates have been reported as 90% after first EBP and 96% after second EBP.23 Side effects and complications of EBP include low back pain, aseptic meningitis, lumbovertebral syndrome, radicular pain, bradycardia, fever, and seizures.

Epidural fibrin glue is a novel modality that has been used when medical therapy and multiple EBPs have failed. Fibrin glue is a preparation of pooled human plasma obtained from plasmapheresis. It is prepared by mixing two solutions: the first contains fibrinogen, factor VIII, fibronectin, aprotinin, and plasminogen; and the second one contains thrombin and calcium. The mixture forms a gel with high tensile strength that tolerates moist environments. It has proven to be a satisfactory technique for stopping cerebrospinal fluid leakage in a series of 20 consecutive craniofacial resections with dural defects.24 Fibrin glue clots do not retract. No signs of an inflammatory response have been reported. Risks include a potential for viral transmission.

In conclusion, post-dural puncture headaches are a known complication of emergency department lumbar puncture. Although the characteristic positional component is usually present, a differential diagnosis must be considered before the assumption of PDPH is made, as other significant complications may arise from a dural puncture.

It is recommended that patients diagnosed with PDPH be medically managed with either caffeine or cosyntropin. A physician may recommend an epidural blood patch as first-line treatment if the resources are available, and this is also the appropriate treatment modality for pharmacologic treatment failures. Fibrin glue or surgical repair should be reserved for the most refractory cases.

References

  1. Silberstein S.D., Marcelis J. Headache associated with changes in intracranial pressure. Headache 1992;32:84.
  2. Olsen J., Bousser M.G., Diener H.C., et al. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004;24:9-160.
  3. Evans R.W., Armon C., Frohman E.M., et al. Assessment: Prevention of post-lumbar puncture headaches: Report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology 2000;55:909.
  4. Landman U.N., Jerome R.M., Glass P.S. Subdural hematoma after atraumatic spinal. J. Clin. Anesthesia 2005;17:379-81.
  5. Zeidan A., Farhat O., Maaliki H., Baraka A. Does postdural puncture headache left untreated lead to subdural hematoma? Case report and review of the literature. Int. J. Obstet. Anesth. 2006;15:50-8. Epub 2005 Oct 26.
  6. Vilming S.T., Kloster R. Pain location and associated symptoms in post-lumbar puncture headache. Cephalgia: Int. J. Headache 1998;10:697-703.
  7. Wilder-Smith E., Kothbauer-Margreiter I., Lammle B., et al. Dural puncture and achieved protein C resistance: risk factors for cerebral venous sinus thrombosis. J. Neurol. Neurosurg. Psychiatry 1997;63:351-6.
  8. Aidi S., Chaunu M.P., Biousse V., Bousser M.G. Changing patter of headache pointing to cerebral venous thrombosis after lumbar puncture and intravenous high-dose corticosteroids. Headache 1999;39:559-64.
  9. Kunkle E.C., Ray B.S., Wolff H.G. Experimental studies on headache: analysis of the headache associated with changes in intracranial pressure. Arch. Neurol. 1949;49:323.
  10. Kokki H., et al. High success rate and low incidence of headache and neurological symptoms with two spinal needle designs in children. Acta. Anesthesiol. Scand. 2005;49:1367-72.
  11. Kuntz K.M., Kokmen E., Stevens J.C., et al. Post-lumbar puncture headaches: experience in 501 consecutive procedures. Neurology 1992;42:1884.
  12. Wu C.L., Rowlingson A.J., Cohen S.R., et al. Gender and post-dural puncture headache. Anesthesiology 2006;105:613-8.
  13. Malhotra S.K., Iyer B.R., Gupta A.K., Raghunathan M., Nakra D. Spinal analgesia and auditory functions: comparison of 2 sizes of Quincke needle. Minerva Anesthesiol. 2006 Dec 12; (Epub ahead of print).
  14. Choi P.T,. et al. PDPH is a common complication of neuraxial blockade in parturients: A meta-analysis of obstetrical studies. Can. J. Anaesth. 2003;50:460-9.
  15. Scavone B.M., et al. Efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture. Anesthesiology 2004;101:1422-7.
  16. Richman J.M., Joe E.M., Cohen S.R., et al. Bevel direction and postdural puncture headache: a meta-analysis. Neurologist 2006;12:224-8.
  17. Lavi R., Yarnitsky D., Rowe J.M., et al. Standard vs atraumatic Whitacre needle for diagnostic lumbar puncture: a randomized trial. Neurology 2006;67:1492-4.
  18. Scavone B.M., Wong C.A., Sullivan J.T., et al. Efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture. Anesthesiology 2004;101:1422-7.
  19. Carter B.L., Pasupuleti R. Use of Intravenous Cosyntropin in the Treatment of Postdural Puncture Headache. Anesthesiology 2000;92:272-4.
  20. Canovas L., Barros C., Gomez A., et al. Use of Intravenous Tetracosactrin in the Treatment of Postdural Puncture Headache: Our Experience in Forty Cases. Anesth. Analg. 2002;94:1369.
  21. Younggren B.N., Zeger W., and Nolan R. Cosyntropin vs. Caffeine for Post-dural Puncture Headaches. Acad. Emerg. Med. 2005;12(Suppl 1):52-3.
  22. Ghoname E.S., Craig W.F., White P.F., et al. The effect of stimulus frequency on the analgesic response to percutaneous electrical nerve stimulation in patients with chronic low back pain. Anesth. Analg. 1999;88:841-6.
  23. Ylonen P., Kokki H. Epidural blood patch for management of postdural puncture headache in adolescents. Acta Anaesthesiol. Scand. 2002;46:794-8.
  24. Crul B.J., Gerritse B.M., van Dongen R.T., Schoonderwaldt H.C. Epidural Fibrin Glue injection stops persistent postdural puncture headache. Anesthesiology 1999;91:576-7.

Contributors

Dr. Brad Younggren is the assistant program director of emergency medicine at Madigan Army Medical Center in Washington. Dr. Emily Merchant is a second-year resident in Madigan's emergency medicine residency program. Medical Editor Dr. Robert C. Solomon is an attending emergency physician at Trinity Health System in Steubenville, Ohio, and clinical assistant professor of emergency medicine at the West Virginia School of Osteopathic Medicine.

Disclosures

In accordance with the Accreditation Council for Continuing Medical Education (ACCME) Standards and American College of Emergency Physicians policy, contributors and editors must disclose to the program audience the existence of significant financial interests in or relationships with manufacturers of commercial products that might have a direct interest in the subject matter.

Dr. Younggren, Dr. Merchant, and Dr. Solomon have disclosed that they have no significant relationships with or financial interests in any commercial companies that pertain to this educational activity.

"Focus On: Post-Dural Puncture Headache" has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME).

ACEP is accredited by the ACCME to provide continuing medical education for physicians.

ACEP designates this educational activity for a maximum of one Category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he or she actually spent in the educational activity.

"Focus On: Post-Dural Puncture Headache" is approved by ACEP for one ACEP Category 1 credit.

Disclaimer

ACEP makes every effort to ensure that contributors to College-sponsored programs are knowledgeable authorities in their fields. Participants are nevertheless advised that the statements and opinions expressed in this article are provided as guidelines and should not be construed as College policy.

The material contained herein is not intended to establish policy, procedure, or a standard of care. The views expressed in this article are those of the contributors and not necessarily the opinion or recommendation of ACEP. The College disclaims any liability or responsibility for the consequences of any actions taken in reliance on those statements or opinions.

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