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Chapter 125. Postdural Puncture Headache

Michael Anderson, MD

  • 22G Quincke = 36%
  • 27G Whitacre = 0%
  • 16G Tuohy = 70%
  • Dural puncture occurs 0–2.6% of the time an epidural is placed for labor analgesia

  • Female gender
  • Age 20–40
  • History of frequent headaches
  • Multiple dural punctures during a procedure
  • Use of a cutting needle rather than pencil-point

  • Headache usually begins 24–48 hours after spinal or epidural; on occasion later. Headache occurring immediately following dural puncture is typically from pneumocephalus, which usually resolves rapidly
  • Headache is usually located in the frontal and occipital regions and often radiates to the neck and shoulders
  • The headache is positional, worsened by sitting up and improved with laying supine
  • Atypical presentations can include tinnitus, diplopia, hearing loss, and photophobia without the presence of a headache. This is from stretching of cranial nerves, and an argument for performing a blood patch early
  • Approximately 40% of parturients will experience a headache that is not a PDPH; therefore, one must discern if the headache is from PDPH or from other causes (i.e., tension headache, preeclampsia, migraine, caffeine withdrawal, meningitis)
  • Anecdotal evidence of decreased PDPH after wet tap if catheter for 24 hours. Weigh the risk of high spinal if an epidural dose of medication is administered intrathecally by mistake, and of infection, versus the risk of PDPH

  • Most headaches resolve spontaneously. Treatment should be a collaborative process between the anesthesiologist and patient
  • Supportive care of fluids, caffeine (500 mg IV or 300 mg oral), and oral analgesics (e.g., APAP/oxycodone) is the first line of treatment

  • Wait 48 hours with conservative treatment before performing blood patch, unless neurologic symptoms are present
  • Anticoagulant or antiplatelet therapy should be stopped with a similar time frame as for any epidural (see Chapter 119)
  • Identify the epidural space (preferably at a lower level than the initial puncture)
  • Fifteen to 20 mL of autologous blood is obtained aseptically and then injected into the epidural space
  • Injection should be slow and end with the development of back pain/pressure or when 20 mL is reached
  • Keep patient supine for about 2 hours following the procedure
  • On occasion, a second blood patch is needed
  • Complications:
    • Bradycardia
    • Abdominal or sciatica pain due to nerve root irritation, typically benign and disappearing after a few days
    • Low-grade fever common
  • If symptoms are still present following two blood patches and the diagnosis is still consistent with PDPH, one should consider specialized consultation and CT imaging to rule out insidious presentation of a subdural hematoma from chronic stretch of the subdural veins
  • Prophylactic blood patch remains controversial; risks and benefits of this technique should be weighed as it does not decrease the incidence but can decrease the severity and duration of the PDPH
  • Surgery for treatment of a dural tear is the last resort

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1. Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003 Nov;91(5):718–729.   [PubMed: 14570796]
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2. Halpern S, Preston R. Postdural ...

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