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Postdural puncture headache (PDPH) was perhaps the first recognized complication of regional anesthesia. Dr. August Bier noted this adverse effect in 1898 in the first patient to undergo successful spinal anesthesia, a 34-year-old laborer undergoing resection of an ulceration of the foot. Bier observed: “Two hours after the operation his back and left leg became painful and the patient vomited and complained of severe headache. The pain and vomiting soon ceased, but headache was still present the next day.”1


The following week, Bier and his assistant, Dr. August Hildebrandt performed experiments on each other. Following the “cocainization of the spinal cord", Bier described firsthand his experience in the days to follow: “I had a feeling of very strong pressure on my skull and became rather dizzy when I stood up rapidly from my chair. All these symptoms vanished at once when I lay down flat, but returned when I stood up … I was forced to take to bed and remained there for nine days, because all the manifestations recurred as soon as I got up … The symptoms finally resolved nine days after the lumbar puncture.”1 Interestingly, since Bier's time, the clinical picture of PDPH has remained unchanged and it remains the most common complication of spinal anesthesia.


Portions of this text originally appeared in the following publication: Neal, Rathmell (eds): Complications in Regional Anesthesia and Pain Management, copyright 2006, published by Elsevier, Philadelphia, PA, USA, with permission.


PDPH occurs following procedures that disrupt the integrity of the meninges. Most cases of PDPH are characterized by their typical onset, quality, and associated symptoms.




Onset of symptoms is generally delayed, with headache usually beginning 12–48 h (rarely > 5 days) following dural puncture. Following dural puncture, 65% experience symptoms within 24 h and 92% within 48 h.2 An onset of symptoms within 1 h is suggestive of pneumocephalus, especially in the context of an epidural loss-of-resistance technique using air.3




The hallmark of PDPH is its postural nature, with symptoms worsening in the upright position and improving with recumbency. The International Classification of Headache Disorders further describes this positional quality as worsening within 15 min of sitting or standing and improving within 15 min after lying down.4 Headache is nearly always bilateral, with a distribution that is frontal (25%), occipital (27%), or both (45%).2 Headaches are typically described as “dull/aching,” “throbbing,” or “pressure-type” in nature.

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Clinical Pearls
  • PDPH occurs following procedures that disrupt the integrity of the meninges (ie dura and arachnoid mater).
  • Onset of symptoms is generally delayed; 65% of patients experience symptoms within 24 h and 92% within 48 h.
  • Onset of symptoms within 1 h is suggestive of pneumocephalus and not PDPH.
  • The hallmark of PDPH is its postural nature, with symptoms worsening in the upright ...

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