OBSTETRIC ANAESTHESIA Tutorial 458

An Update on Effective Management

of the Postdural Puncture Headache
Dr Theunis van Zyl1†, Dr Greg Klar2
1
Anesthesia Resident,
2
Anesthesia Consultant, Kingston General Hospital, Kingston, Canada

Edited by: Dr. Kelly Fedoruk, Clinical Assistant Professor, Department of Anesthesiology,
Perioperative and Pain Medicine, Stanford University, USA
†
Corresponding author email: [email protected]

Published 2 November 2021

KEY POINTS
 Postdural puncture headaches (PDPHs) usually present as a positional headache within 3 days of dural puncture.
 Postpartum headaches require a thorough history and physical exam, as the differential is broad and PDPHs make up
a minority of cases.
 Needle type and size directly impact the rate of PDPH. Small, noncutting needles are recommended when possible.
 Fluids and bedrest are not effective treatments for PDPH, and multimodal analgesia is indicated.
 Sphenopalatine ganglion block is a less invasive alternative to an epidural blood patch, but evidence is limited.
 Epidural blood patch remains the most effective treatment for PDPH.

INTRODUCTION

Toward the evening I was forced to take to bed and remained there for nine days, because all the manifestations recurred
as soon as I got up. At midnight a violent headache set in that quickly became insupportable.
August Bier, 1898: a personal experience of postdural puncture headache

Postdural puncture headache (PDPH) was first described by August Bier in 1898 and classically presents as a postural
headache following therapeutic or diagnostic interventions of the epidural or spinal space.
The incidence of PDPH varies, but is estimated to be 36% or more following lumbar puncture, 0%-10% following spinal
anaesthesia, and 81% following accidental dural puncture during epidural insertion. Rates of accidental dural puncture during
epidural insertion in pregnancy are estimated to be 0.04%-6%.1,2
Although PDPH usually resolves spontaneously, it may interfere with a mother’s ability to care for her newborn and may extend
the length of hospital stay. More rarely, PDPH may be associated with serious complications such as subdural haematoma,
seizures, sagittal sinus thrombosis, and cranial nerve palsies.

PATHOGENESIS AND ANATOMY

The anatomy of the epidural space is shown in Figure 1. The pathogenesis of PDPH remains unclear but is thought to be
caused by cerebrospinal fluid (CSF) leakage into the epidural space via a tear in the meninges. The CSF loss leads to a

An update on Tutorial 181 by Dr. Nicola Jane Campbell

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Figure 1. Anatomy of the dura mater. Illustration ÓChris Gralapp, reproduced with permission. Not for use without permission of copyright holder.

reduction in intracranial pressure and downward traction on pain-sensitive intracranial structures, resulting in a headache that is
classically worse in the upright position. The fall in intracranial pressure may also cause compensatory cerebrovascular
venodilation contributing to the headache.1

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

The fundamental principle in the assessment of a postpartum headache is to carefully consider the differential diagnosis. While
postpartum headaches occur in up to 40% of postpartum women, 50%-75% of postpartum headaches are tension or migraine
headaches, and only 5%-15% are PDPHs.3 Importantly, one study found that 24% of postpartum headaches were due to
preeclampsia, affirming the importance of ruling out serious causes.4 Other often-overlooked causes such as medication
headaches (eg ondansetron) should also be excluded (Table 1).

A history and examination should be performed, taking into account the timing of the headache in relation to the neuraxial
procedure and the nature of the headache, as well as other symptoms and signs. Since PDPH can present following an
unrecognized dural puncture during an epidural, details of the epidural insertion should be reviewed including the difficulty of
the procedure and number of attempts. Following a spinal procedure, PDPH is more likely with a larger-gauge ‘cutting’-tipped
needle (see below) or after multiple attempts at spinal block which might result in a number of dural tears, increasing the
chance of a CSF leak.

Infective
Meningitis
Encephalitis
Vascular
Migraine
Cerebral vein thrombosis
Cerebral infarction
Subdural hematoma
Subarachnoid hemorrhage
Neoplastic
Space occupying lesion
Pharmacological/Metabolic
Dehydration
Caffeine withdrawal
Medication side effect (eg ondansetron)
Other
Postdural puncture headache
Preeclampsia
Tension headache
Benign intracranial hypertension
Pneumocephalus
Lactation headache
Table 1. Causes of Postpartum Headache

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Figure 2. A comparison of different spinal needle tips. Figure reprinted from Moghtaderi et al. 2012. Emergency Medicine—An International
Perspective: InTech 2012:43-48.6Image licensed under a Creative Commons Attribution 3.0 License.6

The cardinal features of PDPH as defined by the International Headache Society are a headache occurring within 5 days of
lumbar puncture caused by CSF leakage through the dural puncture. It is usually accompanied by neck stiffness and/or
subjective hearing symptoms. It remits spontaneously within 2 weeks, or after sealing the leak with autologous epidural lumbar
patch. However, PDPH can occur later and continue for longer than these times, with case reports of PDPH lasting for years.
Presentation is often variable but classic features include the following:
 Headache is often frontal-occipital.
 Usually develops 24 to 48 hours after the procedure with 90% of headaches presenting within 3 days.1
 Headache is worse in the upright position and eases when supine.
 Pressure over the abdomen with the patient in the upright position may give transient relief to the headache by raising
intracranial pressure secondary to a rise in intra-abdominal pressure (Gutsche sign).
 Associated symptoms include neck stiffness, photophobia, tinnitus, visual disturbance, and cranial nerve palsies.
Skin over the epidural or spinal puncture site should be inspected for inflammation and tenderness and vital signs should be
recorded. PDPH is a clinical diagnosis; however, diagnostic imaging should be considered early if there is concern for more
serious intracranial pathology. In cases of PDPH, magnetic resonance imaging may demonstrate diffuse meningeal
enhancement and brain descent.1

PREVENTION
Spinal Needle Selection
Smaller spinal needles and pencil-point tips such as the Whitacre and Sprotte needles are associated with lower rates of PDPH
than larger or cutting-tip needles.1 A common belief is that pencil-point needles part, rather than cut, the dural fibers, resulting in
less trauma and decreased incidence of PDPH. However, scanning electron microscopy demonstrates that cutting-tip needles
produced a U-shaped flap while pencil-point needles created a traumatic tearing of meningeal fibers. It is believed that an
inflammatory response to the tearing results in closure of the lesion and decreased incidence of PDPH.5 Ideally, pencil-point
spinal needles no larger than 25 gauge should be used (Figure 2).

Neuraxial Block Technique

Epidurals can be inserted using a loss of resistance to saline (LORS) or to air (LORA). Inadvertent dural puncture while using
loss of resistance to airmay result in pneumocephalus, which itself can cause headache. Despite suggestions that loss of
resistance to saline is preferable to loss of resistance to air, a meta-analysis of prospective, randomized trials found no
difference in rates of accidental dural puncture or PDPH between air or saline.7
Bevel orientation of spinal and epidural needles during insertion has been shown to influence the rate of PDPH with lower
incidence of headache if bevel orientation is ‘parallel’ to dural fibers.1 However, given evidence that dural fibers do not run
longitudinally and are not arranged in a parallel structure, the mechanism of this is still unclear.5
Other precautions include optimal patient positioning, slow controlled advancement of the needle, and limiting patient
movement during the procedure by using adequate local anaesthetic infiltration to overlying soft tissue and maintaining verbal
contact throughout. Operator experience is inversely related to inadvertent dural puncture and PDPH rates. Fatigue, sleep
deprivation, and shift work are other important factors that may contribute to PDPH rate.1
After accidental dural puncture with a Tuohy needle, placement of the epidural catheter through the dural perforation may
reduce the likelihood and severity of PDPH. This is thought to be due to an inflammatory response to the catheter, which
promotes healing and reduces CSF leakage. Randomized trials are limited, evidence is conflicting, and how long the catheter

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should be left in place is unclear. One meta-analysis found a nonsignificant decrease in PDPH but a significant reduction in
need for an epidural blood patch (EBP).8 The risks of leaving an intrathecal catheter include infection and drug overdose and
hence the catheter should be clearly labelled.
Following diagnostic lumbar puncture, replacing the stylet prior to removing the needle may reduce the risk of headache. Stylet
insertion may prevent a strand of arachnoid that was trapped in the needle following CSF aspiration from being avulsed on
needle withdrawal, reducing damage to the dura.9

MANAGEMENT
Conservative Management
Most PDPHs resolve spontaneously. Conservative management has traditionally involved bed rest and fluids, though there is
little evidence to support either. A Cochrane review on fluids and bedrest for treating PDPH was updated in 2016 and concluded
that routine bed rest and fluids after dural puncture is not beneficial,2 yet despite this it continues to be recommended by
physicians.

Pharmacological Management
Many treatment modalities have been recommended to treat PDPH; however, evidence of effectiveness for most is limited.
Multimodal analgesia should be instituted in all patients with PDPH; regular acetaminophen and nonsteroidal anti-inflammatory
medications may control symptoms adequately.

Caffeine
Caffeine is thought to treat PDPH by inducing cerebral vasoconstriction. Doses from 75 to 500 mg, orally and intravenously,
both one-time and repeated, have been studied. A Cochrane review in 2015 concluded there is evidence that caffeine confers a
temporary benefit in PDPH compared to placebo; however, the evidence quality was poor.10 Caffeine is associated with
adverse events including cardiac arrhythmias and seizures, and high doses may enter breast milk and lead to neonatal
irritability.

Corticotropin Analogues
Synthetic corticotropin was reported for treating PDPH in the 1990s. Postulated mechanisms include CSF retention through
mineralocorticoid-mediated sodium reabsorption, and a direct analgesic effect via its glucocorticoid activity. Most reports of its
effectiveness stem from case reports and case series; however, a randomized controlled trial in 2004 found no effect of a single
intramuscular injection of Synacthen compared with placebo.11

Other Medications
Numerous other reports exist in the literature with for a variety of other pharmacological agents, most with a mechanism
involving vasoconstriction. Some of these include serotonin agonists (egsumatriptan), methylergonovine, gabapentin,
theophylline, and hydrocortisone.11 While some evidence suggests gabapentin, theophylline, and hydrocortisone decreased
pain scores, no intervention reduced need for an EBP. In addition, the evidence is of low quality as all studies were small with
short follow-up, and further research is required.10
One recent randomized, double-blind, controlled trial of obstetrics patients with PDPH found that neostigmine and atropine
significantly decreased pain scores, and no patient in the study group required an EBP. The proposed mechanism is cerebral
vasoconstriction and increased CSF production.12 However, no other studies have investigated this, and further research is required.

Invasive Management
Sphenopalatine Ganglion Block
A sphenopalatine ganglion block (SPGB) is a recent treatment option for PDPH that has been used in the past for treating
migraines. The sphenopalatine ganglion is a collection of parasympathetic cells located in bilateral nares posterior to the middle
nasal concha in the nasopharynx. The proposed mechanism of action is a block of the sphenopalatine ganglion
parasympathetic-induced cerebral vasodilation.13

Technique
 Have the patient lie supine in a sniffing position.
 Soak a long cotton-tipped applicator in local anaesthetic (2%-4% lidocaine, 0.5% ropivacaine, or 0.5% bupivacaine).

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Figure 3. Sphenopalatine ganglion block location. Figure reprinted from Machado et al. 2009.14 BrJP 2(4), 392-394. Image licensed under a
Creative Commons Attribution License.

 Insert cotton-tipped applicator into patient’s nare aiming straight back.

 Advance until the posterior nasopharynx wall is reached and resistance is felt.
 Leave applicator in place and in contact with sphenopalatine ganglion for 10 minutes, then remove.
Adverse events include nausea, bitter taste, discomfort during insertion of applicator, and nasal or throat pain.
The SPGB has been described in case reports and series, and in one retrospective cohort as an effective treatment for PDPH.
However, just recently a randomized, blinded, controlled trial compared SPGB using local anaesthetic–soaked cotton swabs to
placebo swabs. This study found a large decrease in pain scores for both placebo and local anaesthetic groups, and no
difference in rates of EBPs, suggesting a placebo as the cause of SPGB’s reported effectiveness (Figure 3).13

Epidural Blood Patch

After the observation that patients with bloody spinal taps at lumbar puncture were less likely to develop PDPH, the first EBP
was performed in 1960. Just 2 mL of the patient’s blood was injected during the first EBP and the headache was relieved.
Epidural blood patching involves injection of autologous blood into the epidural space. It remains one of the few proven
treatments of PDPH; however, the mechanism of action remains unclear. The resulting blood clot may have a ‘patch effect’ on
the dural tear while the volume of blood transfused into the epidural space raises intracranial pressure.

Effectiveness
Early studies of the efficacy of EBPs (up to 90%) were overestimates due to inadequate patient follow-up, as evidence
suggests pain can reoccur after an initial period of relief.15 Data suggest that complete, permanent relief of PDPH by a single
blood patch occurs in 31%-50% of patients after puncture with an epidural needle, and up to 75% after a spinal needle.
Complete or partial relief occurs in approximately 90% of patients.15–17 About 30% of patients require a second blood
patch.15,16 Needle diameter smaller than 20 gauge is also a predictor of partial or failed response to EBP.17 Despite recent
data, EBP remains the most effective treatment for PDPH and is more effective than conservative management in treating
established PDPH.18

Optimal Technique
 An EBP should be performed by two personnel: one an experienced anaesthetist, the other competent in taking a volume of
blood from the arm. Both should employ full aseptic precautions.
 Contraindications include sepsis, coagulopathy, and patient refusal.
 Timing of EBP performance is somewhat controversial, with limited evidence pointing to less failure (ie return of headache
and need for subsequent EBP) when performed more than 48 hours after PDPH onset. However, failure of earlier EBPs may
be due to larger, more difficult to treat dural punctures presenting earlier, and waiting to offer EBP until after 48 hours has
passed may unnecessarily prolong patient discomfort and distress.16

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 Volumes of between 2 and 60 mL of blood have been described in literature. A randomized, controlled trial in 2011 compared
15, 20, and 30 mL of blood for an EBP. The study suggests that a volume of 20 mL is a reasonable volume to use as it
resulted in lower headache pain scores and less back pain during injection. Injection should be stopped if the patient
experiences pain during the procedure.16
 Most anaesthesiologists recommend the patient lie flat for 1 to 2 hours after the procedure and avoid heavy lifting for 48
hours; however, evidence supporting this is lacking.19

Safety
 Strict asepsis must be maintained during an EBP.
 Do not perform in the presence of leucocytosis or fever due to the risk of meningitis.
 Minor complications include backache, neck ache, and transient bradycardia.
 Major complications are rare and include meningitis, subdural haematoma, seizures, arachnoiditis, and dural puncture.15,16
 An EBP may be unacceptable to Jehovah’s Witness patients, so thorough informed consent detailing the procedure,
alternatives, risks, and benefits should be performed in these and all patients.
 If an EBP fails to relieve a PDPH, it may be prudent to consider head imaging to exclude other pathology prior to a repeat
EBP.

Prophylactic EBP
An attractive option after accidental dural puncture is a prophylactic EBP (PEBP) in the hope of preventing a subsequent
PDPH. Unfortunately, PEBP did not decrease the risk of PDPH compared to a sham procedure, and a Cochrane review
concluded that PEBP could not be recommended over other treatments.18 In addition, not all dural punctures cause PDPH and
many PDPHs do not require an EBP. Therefore, PEBP following dural puncture may expose patients to an unnecessary
procedure with associated risks.

Other Techniques
Epidural Fluids
Both infusions and boluses of saline into the epidural space have been studied. While both may transiently increase the CSF
pressure and provide temporary relief of the headache, longer-term relief is not seen.1

Neuraxial Morphine
A small randomized trial found that 3 mg epidural morphine reduced the development of PDPH and need for EBP following
accidental dural puncture. A more recent randomized trial in 2020 found that intrathecal morphine did not decrease
development of PDPH or rates of EBP.20 Further research is required.

SUMMARY
In summary, PDPH is usually a self-limited, positional headache that can occur following dural puncture but may be
very painful and have a significant impact on a patient’s functional ability. A broad differential diagnosis is critical when
evaluating a suspected PDPH as there are many alternative causes, including serious and life-threatening conditions.
While there are multiple potential pharmacological treatments, many lack strong evidence to support their efficacy.
The SPGB is a newer treatment modality that offers an alternative to an EBP. However, further evidence is required to
determine its true efficacy. An EBP remains the most effective treatment for PDPH.

REFERENCES
1. Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth.
2003;91(5):718-729.
2. Arevalo-Rodriguez I, Ciapponi A, Roqué-Figuls M, Muñoz L, Cosp XB. Posture and fluids for preventing post-dural
puncture headache. Cochrane Database Syst Rev. 2016;3: CD009199. doi:10.1002/14651858.CD009199.pub3
3. Goldszmidt E, Kern R, Chaput A, Macarthur A. The incidence and etiology of postpartum headaches: a prospective cohort
study. Can J Anaesth. 2005;52(9):971.
4. Stella CL, Jodicke CD, How HY, et al. Postpartum headache: is your work-up complete? Am J Obstet Gynecol.
2007;196(4):318-e1.

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 5. Reina MA, de Leon-Casasola OA, Lopez A, et al. An in vitro study of dural lesions produced by 25-gauge Quincke and
Whitacre needles evaluated by scanning electron microscopy. Reg Anesth Pain Med. 2000;25(4):393-402.
6. Moghtaderi A, Alavi-Naini R, Sanatinia S. Lumbar puncture: techniques, complications and CSF analyses. In: Blaivas M,
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7. Schier R, Guerra D, Aguilar J, et al. Epidural space identification: a meta-analysis of complications after air versus liquid
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analysis. Int J Obstet Anesth. 2013; 22(1):26-30.
9. Strupp M, Brandt T, Müller A. Incidence of post-lumbar puncture syndrome reduced by reinserting the stylet: a randomized
prospective study of 600 patients. J Neurol. 1998;245(9):589-592.
10. Ona XB, Osorio D, Cosp XB. Drug therapy for treating post-dural puncture headache. Cochrane Database Syst Rev.
2015;7:CD007887. doi:10.1002/14651858.CD007887.pub3
11. Russell R, Laxton C, Lucas DN, et al. Treatment of obstetric post-dural puncture headache. Part 1: conservative and
pharmacological management. Int J Obstet Anesth. 2019;38:93-103.
12. AA, Mansour AZ, Yassin HM, et al. Addition of neostigmine and atropine to conventional management of postdural
puncture headache: a randomized controlled trial. Anesth Analg. 2018;127(6):1434-1439.
13. Jespersen MS, Jaeger P, Ægidius KL, et al. Sphenopalatine ganglion block for the treatment of postdural puncture
headache: a randomised, blinded, clinical trial. Br J Anaesth. 2020;124(6):739-747.
14. Machado FC, Carone G, Ashmawi HA. Sphenopalatine ganglion block for post-dural puncture headache after invasive
cerebrospinal fluid pressure monitoring. Case report. BrJP. 2019;2:392-394.
15. Banks S, Paech M, Gurrin L. An audit of epidural blood patch after accidental dural puncture with a Tuohy needle in
obstetric patients. Int J Obstet Anesth. 2001;10(3):172-176.
16. Paech MJ, Doherty DA, Christmas T, et al. The volume of blood for epidural blood patch in obstetrics: a randomized,
blinded clinical trial. Anesth Analg. 2011;113(1):126-133.
17. Safa-Tisseront V, Thormann F, Malassiné P, et al. Effectiveness of epidural blood patch in the management of post–dural
puncture headache. Anesthesiology. 2001;95(2):334-339.
18. Boonmak P, Boonmak S. Epidural blood patching for preventing and treating post-dural puncture headache. Cochrane
Database Syst Rev. 2010;1:CD001791. doi:10.1002/14651858.CD001791.pub2
19. Russell R, Laxton C, Lucas DN, et al. Treatment of obstetric post-dural puncture headache. Part 2: epidural blood patch.
Int J Obstet Anesth. 2019;38:104-118.
20. Peralta FM, Wong CA, Higgins N, et al. prophylactic intrathecal morphine and prevention of post–dural puncture
headache: a randomized double-blind trial. Anesthesiology. 2020;132(5):1045-1052.

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