Post-lumbar puncture headache
- Christina Sun-Edelstein, MD
Christina Sun-Edelstein, MD
- Department of Clinical Neurosciences
- St. Vincent's Hospital
- Christine L Lay, MD, FRCPC
Christine L Lay, MD, FRCPC
- Associate Professor
- Women's College Hospital
- Section Editor
- Jerry W Swanson, MD, MHPE
Jerry W Swanson, MD, MHPE
- Section Editor — Headache
- Professor of Neurology
- Mayo Clinic College of Medicine
Headache, which occurs in 10 to 30 percent of patients following lumbar puncture, is one of the most common complications of the procedure. Post-lumbar puncture headache (PLPHA; also known as post-dural puncture headache) is caused by leakage of cerebrospinal fluid from the dura with resultant traction on pain-sensitive structures.
This topic will review PLPHA. The technique of lumbar puncture is discussed separately. (See "Lumbar puncture: Technique, indications, contraindications, and complications in adults".)
Other conditions related to altered cerebrospinal fluid pressure are reviewed elsewhere. (See "Cerebrospinal fluid: Physiology and utility of an examination in disease states" and "Spontaneous intracranial hypotension: Pathophysiology, clinical features, and diagnosis" and "Idiopathic intracranial hypertension (pseudotumor cerebri): Epidemiology and pathogenesis" and "Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis".)
In 1891 Quincke introduced the lumbar puncture (LP) , and in 1898 Bier suffered from and was the first to report PLPHA . He proposed that ongoing leakage of cerebrospinal fluid (CSF) through the dural puncture site was the cause of the headache. This belief is maintained today; it is supposed that CSF leakage through the dural rent made by the LP needle exceeds the rate of CSF production, resulting in low CSF volume and pressure . The reported incidence of PLPHA ranges from 10 to 30 percent [2,3].
Of note, cerebral venous thrombosis must also be considered as a possible cause of persisting headache following LP, since LP can rarely precipitate a cerebral venous thrombosis. However, unlike PLPHA, the headache related to cerebral venous thrombosis does not typically change with posture, and the severity usually increases in the acute phase of illness. (See "Etiology, clinical features, and diagnosis of cerebral venous thrombosis".)
Subscribers log in hereLiterature review current through: Jun 2017. | This topic last updated: Jun 13, 2017.References
- Silberstein SD, Marcelis J. Headache associated with changes in intracranial pressure. Headache 1992; 32:84.
- Raskin NH. Lumbar puncture headache: a review. Headache 1990; 30:197.
- Fernández E. Headaches associated with low spinal fluid pressure. Headache 1990; 30:122.
- Amorim JA, Gomes de Barros MV, Valença MM. Post-dural (post-lumbar) puncture headache: risk factors and clinical features. Cephalalgia 2012; 32:916.
- Morgenlander JC. Lumbar puncture and CSF examination. Answers to three commonly asked questions. Postgrad Med 1994; 95:125.
- Kuntz KM, Kokmen E, Stevens JC, et al. Post-lumbar puncture headaches: experience in 501 consecutive procedures. Neurology 1992; 42:1884.
- Evans RW, Armon C, Frohman EM, Goodin DS. 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.
- Armon C, Evans RW, Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Addendum to assessment: Prevention of post-lumbar puncture headaches: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005; 65:510.
- Bertolotto A, Malentacchi M, Capobianco M, et al. The use of the 25 Sprotte needle markedly reduces post-dural puncture headache in routine neurological practice. Cephalalgia 2016; 36:131.
- Zorrilla-Vaca A, Healy R, Zorrilla-Vaca C. Finer gauge of cutting but not pencil-point needles correlate with lower incidence of post-dural puncture headache: a meta-regression analysis. J Anesth 2016; 30:855.
- Dieterich M, Perkin GD. Post-lumbar puncture headache syndrome. In: Neurologic Disorders: Course and Treatment, Brand T, Caplan LR, Dichland J, et al (Eds), Academic Press, San Diego 1996. p.59.
- Morewood GH. A rational approach to the cause, prevention and treatment of postdural puncture headache. CMAJ 1993; 149:1087.
- Straus SE, Thorpe KE, Holroyd-Leduc J. How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis? JAMA 2006; 296:2012.
- 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; 245:589.
- Vallejo MC, Mandell GL, Sabo DP, Ramanathan S. Postdural puncture headache: a randomized comparison of five spinal needles in obstetric patients. Anesth Analg 2000; 91:916.
- Santanen U, Rautoma P, Luurila H, et al. Comparison of 27-gauge (0.41-mm) Whitacre and Quincke spinal needles with respect to post-dural puncture headache and non-dural puncture headache. Acta Anaesthesiol Scand 2004; 48:474.
- Strupp M, Schueler O, Straube A, et al. "Atraumatic" Sprotte needle reduces the incidence of post-lumbar puncture headaches. Neurology 2001; 57:2310.
- Arevalo-Rodriguez I, Muñoz L, Godoy-Casasbuenas N, et al. Needle gauge and tip designs for preventing post-dural puncture headache (PDPH). Cochrane Database Syst Rev 2017; 4:CD010807.
- 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; 25:393.
- Lavi R, Yarnitsky D, Rowe JM, et al. Standard vs atraumatic Whitacre needle for diagnostic lumbar puncture: a randomized trial. Neurology 2006; 67:1492.
- Tung CE, So YT, Lansberg MG. Cost comparison between the atraumatic and cutting lumbar puncture needles. Neurology 2012; 78:109.
- Thomas SR, Jamieson DR, Muir KW. Randomised controlled trial of atraumatic versus standard needles for diagnostic lumbar puncture. BMJ 2000; 321:986.
- Bolder PM. Postlumbar puncture headache in pediatric oncology patients. Anesthesiology 1986; 65:696.
- Vilming ST, Schrader H, Monstad I. Post-lumbar-puncture headache: the significance of body posture. A controlled study of 300 patients. Cephalalgia 1988; 8:75.
- Thoennissen J, Herkner H, Lang W, et al. Does bed rest after cervical or lumbar puncture prevent headache? A systematic review and meta-analysis. CMAJ 2001; 165:1311.
- Ebinger F, Kosel C, Pietz J, Rating D. Strict bed rest following lumbar puncture in children and adolescents is of no benefit. Neurology 2004; 62:1003.
- Arevalo-Rodriguez I, Ciapponi A, Roqué i Figuls M, et al. Posture and fluids for preventing post-dural puncture headache. Cochrane Database Syst Rev 2016; 3:CD009199.
- Boonmak P, Boonmak S. Epidural blood patching for preventing and treating post-dural puncture headache. Cochrane Database Syst Rev 2010; :CD001791.
- van Kooten F, Oedit R, Bakker SL, Dippel DW. Epidural blood patch in post dural puncture headache: a randomised, observer-blind, controlled clinical trial. J Neurol Neurosurg Psychiatry 2008; 79:553.
- Seebacher J, Ribeiro V, LeGuillou JL, et al. Epidural blood patch in the treatment of post dural puncture headache: a double blind study. Headache 1989; 29:630.
- Sandesc D, Lupei MI, Sirbu C, et al. Conventional treatment or epidural blood patch for the treatment of different etiologies of post dural puncture headache. Acta Anaesthesiol Belg 2005; 56:265.
- Mokri B. Low cerebrospinal fluid pressure syndromes. Neurol Clin 2004; 22:55.
- Sechzer PH, Abel L. Post-spinal anesthesia headache treated with caffeine. Evaluation with demand method. Part 1. Curr Ther Res Clin Exp 1978; 24:307.
- Sechzer PH. Post-spinal anesthesia headache treated with caffeine. Part II: Intracranial vascular distention, a key factor. Curr Ther Res Clin Exp 1979; 26:440.
- Camann WR, Murray RS, Mushlin PS, Lambert DH. Effects of oral caffeine on postdural puncture headache. A double-blind, placebo-controlled trial. Anesth Analg 1990; 70:181.
- Jarvis AP, Greenawalt JW, Fagraeus L. Intravenous caffeine for postdural puncture headache. Anesth Analg 1986; 65:316.
- RICE GG, DABBS CH. The use of peridural and subarachnoid injections of saline solution in the treatment of severe postspinal headache. Anesthesiology 1950; 11:17.
- Foster P. ACTH treatment for post-lumbar puncture headache. Br J Anaesth 1994; 73:429.
- Gupta S, Agrawal A. Postdural puncture headache and ACTH. J Clin Anesth 1997; 9:258.
- Cánovas L, Barros C, Gómez A, et al. Use of intravenous tetracosactin in the treatment of postdural puncture headache: our experience in forty cases. Anesth Analg 2002; 94:1369.
- Rucklidge MW, Yentis SM, Paech MJ. Synacthen Depot for the treatment of postdural puncture headache. Anaesthesia 2004; 59:138.
- Hanling SR, Lagrew JE 2nd, Colmenar DH, et al. Intravenous Cosyntropin Versus Epidural Blood Patch for Treatment of Postdural Puncture Headache. Pain Med 2016.
- Erol DD. The effect of oral gabapentin on postdural puncture headache. Acute Pain 2006; 8:169.
- Noyan Ashraf MA, Sadeghi A, Azarbakht Z, et al. Evaluation of intravenous hydrocortisone in reducing headache after spinal anesthesia: a double blind controlled clinical study [corrected]. Middle East J Anaesthesiol 2007; 19:415.
- Feuerstein TJ, Zeides A. Theophylline relieves headache following lumbar puncture. Placebo-controlled, double-blind pilot study. Klin Wochenschr 1986; 64:216.
- Connelly NR, Parker RK, Rahimi A, Gibson CS. Sumatriptan in patients with postdural puncture headache. Headache 2000; 40:316.
- Cohen S, Sakr A, Katyal S, Chopra D. Sphenopalatine ganglion block for postdural puncture headache. Anaesthesia 2009; 64:574.
- Basurto Ona X, Martínez García L, Solà I, Bonfill Cosp X. Drug therapy for treating post-dural puncture headache. Cochrane Database Syst Rev 2011; :CD007887.
- Halker RB, Demaerschalk BM, Wellik KE, et al. Caffeine for the prevention and treatment of postdural puncture headache: debunking the myth. Neurologist 2007; 13:323.
- Kent S, Mehaffey G. Transnasal sphenopalatine ganglion block for the treatment of postdural puncture headache in the ED. Am J Emerg Med 2015; 33:1714.e1.