Learning objectives

• Recognize the risk factors for PDPH
• Recognize signs and symptoms of PDPH
• Take measures to reduce the risk of PDPH
• Make diagnostic assessments for PDPH
• Manage PDPH occurrence

Definition & mechanisms

• Post-dural puncture headache (PDPH) is a headache occurring within 5 days of a dural puncture, caused by cerebrospinal fluid leakage through the puncture
• It is usually accompanied by neck stiffness and/or subjective hearing symptoms
• PDPH usually remits spontaneously within 2 weeks

Risk factors

• Patient-related:
  • Age: Uncommon in patients less than 10 years of age; peak incidence is in the teens and early 20s
  • Gender: Nonpregnant females have twice the risk compared to age-matched men
• Equipment related:
  • Needle gauge (larger > smaller)  
  • Needle tip design (cutting > noncutting)

Risk management after accidental dural puncture

• Stylet Replacement
• Subarachnoid Saline
• Intravenous Cosyntropin
• Limiting/Avoiding Pushing during labor
• Intrathecal Catheters
• Epidural Saline
• Epidural Opiates
• Prophylactic Epidural Blood Patch

Signs & symptoms

• Most cases of PDPH will be typical in
  • Onset—often delayed, but within 48 hours
  • Presentation—symmetric, bilateral headache
  • Associated symptoms—more likely with severe headache

• Symptoms:
  • Headache accompanied by at least one of these symptoms:
  • Neck stiffness
  • Tinnitus
  • Hypoacusia
  • Photophobia
  • Nausea

Diagnosis

• PDPH diagnosis remains a diagnosis of exclusion, it is critical to rule out other etiologies
  • Benign etiologies
    • Nonspecific headache
    • Exacerbation of chronic headache (e.g., tension-type headache)
    • Hypertensive headache
    • Pneumocephalus
    • Sinusitis
    • Drug-related side effect
    • Spontaneous intracranial hypotension
    • Other

• • Serious etiologies
    • Meningitis
    • Subdural hematoma (SDH)
    • Subarachnoid hemorrhage
    • Preeclampsia/eclampsia
    • Intracranial venous thrombosis (ICVT)
    • Other

Management

Keep in mind

• There is no evidence to support the common practice of recommending bed rest and aggressive hydration in the prevention of PDPH
• PDPH may carry a risk of medicolegal liability
• ADP may result in chronic headache and back pain
• Anesthetic procedures with risk of PDPH require proper informed consent

Suggested reading

• Statement on post-dural puncture headache management. American Society of Anesthesiologists (ASA). https://www.asahq.org. Published October 13, 2021. Accessed December 14, 2022.
• Russell R, Laxton C, Lucas DN, Niewiarowski J, Scrutton M, Stocks G. Treatment of obstetric post-dural puncture headache. Part 2: epidural blood patch. Int J Obstet Anesth. 2019;38:104-118

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