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The incidence of postdural puncture headache (PDPH) varies widely, depending on patient population, the experience level of care providers, and the size and type of the needle. The Society for Obstetric Anesthesia and Perinatology Center of Excellence sets the benchmark rate of unintentional dural puncture (UDP) at ≤2%.

The mechanism of PDPH after unintentional dural puncture (UDP) derives from leakage of cerebrospinal fluid (CSF), resulting in low CSF pressure. In the upright position, low CSF pressure causes vascular dilation and the loss of cushioning effect leads to stretching intracranial vasculature and cranial nerves. The most commonly affected cranial nerves are the abducens nerve (VI) and vestibulocochlear nerve (VIII); both nerves are prone to stretch and compression due to their long path at the cranial base.

Prompt treatment of PDPH can greatly improve maternal recovery after delivery and enhance the ability to take care of newborn babies. Although untreated PDPH can resolve within 2 weeks, severe adverse outcomes, such as subdural hematoma, can occur. Fortunately, these have an extremely low incidence.1 Recent evidence shows PDPH may be associated with long-term headache, backache, and depression.2


  • Female gender

  • Pregnancy

  • Younger age

  • Low body mass index (BMI): higher incidence of UDP due to much shorter distance from the skin to epidural space; higher incidence of PDPH after UDP due to greater pressure gradient between lumbar CSF pressure and epidural pressure compared to high BMI patients

  • Needle size: the incidence of PDPH can be as high as 81% to 88% after UDP with 17G epidural needle in pregnant women3

  • Shape and orientation of the needle tip


  • Positional headache that occurs within 5 days after a dural puncture. The positional nature is no longer required for diagnosis due to ∼10% atypical headache.4

  • Positional neck pain/stiffness, with or without headache, is also diagnostic.

  • PDPH can be accompanied by photophobia, diplopia, nausea, vomiting, and subjective hearing symptoms.

  • Headache that is not better accounted for by other causes in the postpartum period, including stress/tension headache, caffeine withdrawal, sleep deprivation, migraine headache, preeclampsia, subarachnoid hemorrhage, and cortical vein thrombosis.


Neurologic Complications Associated with PDPH5

UDP and PDPH increase the risks of the following neurologic complications:

  • Cerebral venous thrombosis (odds ratios [OR] 19)

  • Subdural hematoma (OR 19)

  • Bacterial meningitis (OR 39.7)

  • Persistent chronic headache

  • Possible permanent diplopia or hearing change


The goals to actively treat PDPH:

  • Alleviate the symptoms and allow mothers to take care of their newborns.

  • Prevent neurological complications, such as subdural hematoma, hearing change, and diplopia.


Management of postdural puncture headache. EBP, ...

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