Post-lumbar puncture headache

Background

10-36% of patients develop headache within 24-48hrs post-LP
Due to persistent CSF leak
Also known as "Postdural Puncture Headaches"
A 2018 meta analysis showed atraumatic needles had a lower incidence of post-LP headache and need for blood patch when compared to sharp needles[1]

Clinical Features

Worsening with upright position and relief with recumbency

Differential Diagnosis

Headache

Common

Killers

Meningitis/encephalitis
- Neoplastic meningitis
Myocardial ischemia
Retropharyngeal abscess
Intracranial Hemorrhage (ICH)
- SAH / sentinel bleed
Acute obstructive hydrocephalus
Space occupying lesions
CVA
Carbon monoxide poisoning
Basilar artery dissection
Preeclampsia
Cerebral venous thrombosis
Hypertensive emergency
Depression

Maimers

Giant cell arteritis of temporal artery (temporal arteritis)
Idiopathic intracranial hypertension (Pseudotumor Cerebri)
Acute Glaucoma
Acute sinusitis
Cavernous sinus thrombosis or cerebral sinus thrombosis
Carotid artery dissection

Others

Trigeminal neuralgia
TMJ pain
Post-lumbar puncture headache
Dehydration
Analgesia abuse
Various ocular and dental problems
Herpes zoster ophthalmicus
Herpes zoster oticus
Cryptococcosis
Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
Ophthalmoplegic migraine
Superior Vena Cava Syndrome

Aseptic Meningitis

Viral
- Varicella
- Herpes
- Enterovirus
- West Nile
Tuberculosis
Lyme disease
Syphilis
Leptospirosis
Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
Noninfectious

Evaluation

Normally by history

Management

Simple analgesics
IV fluids
IV caffeine[2]
- 500mg (in 1 L of NS) over 1 hour, followed by 1 L of NS x 1 hour
- Give second dose in 4 hours if pain persists
Blood patch if above fails

Prevention

Minimize risk by:
- Orienting needle bevel parallel to longitudinal fibers of dura
- Using smaller-bore needles (22 gauge or smaller)
- Using atraumatic needles
- Stylet replacement before needle removal
Recumbency and bedrest NOT effective

See Also

Lumbar Puncture

References

Atraumatic Versus Conventional Lumbar Puncture Needles: A Systematic Review And Meta-Analysis Nath, S., et al, Lancet 391(10126):1197, March 24, 2018
Yücel A, Ozyalçin S, Talu GK, et al. Intravenous administration of caffeine sodium benzoate for postdural puncture headache. Reg Anesth Pain Med 1999; 24:51.

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