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Post Dural Puncture Headache
When the dura is intentionally or accidentally punctured, the potential for headache exists. The clinical presentation of post–dural puncture headache is classic and makes the diagnosis straightforward if considering this diagnostic category of headache.
The diagnosis may be obscured if the clinician is unaware that dural puncture may have occurred or in the rare instance when this type of headache occurs spontaneously after a bout of sneezing or coughing. The symptoms and rare physical findings associated with post–dural puncture headache are due to low cerebrospinal fluid pressure resulting from continued leakage of spinal fluid out of the subarachnoid space.
The symptoms of post–dural puncture headache begin almost immediately after the patient moves from a horizontal to an upright position. The intensity peaks within 1 or 2 minutes and abates within several minutes of the patient again assuming the horizontal position.
The headache is pounding in character, and its intensity is severe, with the intensity increasing the longer the patient remains upright. The headache is almost always bilateral and located in the frontal, temporal, and occipital regions.
Nausea and vomiting and dizziness frequently accompany the headache pain, especially if the patient remains upright for long periods. If cranial nerve palsy occurs, visual disturbance may occur. Post–dural puncture headache is also known as spinal headache.
What are the Symptoms of post dural puncture headache
The diagnosis of post dural puncture headache is most often made on the basis of clinical history rather than physical findings on examination.
The neurological examination in most patients suffering from post dural puncture headache is normal. If the spinal fluid leak is allowed to persist, or if the patient remains in the upright position for long periods despite the headache, cranial nerve palsies may occur, with the sixth cranial nerve affected most commonly.
This complication may be transient, but may become permanent, especially in patients with vulnerable nerves, such as those with diabetes. If the neurological examination is abnormal, other causes of headache should be considered, including subarachnoid hemorrhage.
The onset of headache pain and other associated symptoms such as nausea and vomiting that occurs when the patient moves from the horizontal to the upright position and then abates when the patient resumes a horizontal position is the sine qua non of post–dural puncture headache.
A history of intentional dural puncture, such as lumbar puncture, spinal anesthesia, or myelography, or accidental dural puncture, such as failed epidural block or dural injury during spinal surgery, strongly points to the diagnosis of post–dural puncture headache.
As mentioned, a spontaneous postural headache that manifests identically to headache after dural puncture can occur after bouts of heavy sneezing or coughing and is thought to be due to traumatic rents in the dura. In this setting, a diagnosis of post–dural puncture headache is one of exclusion.
How is post dural puncture headache diagnosed?
Magnetic resonance imaging (MRI) with and without gadolinium is highly accurate in helping confirm the diagnosis of post–dural puncture headache. Enhancement of the dura with low-lying cerebellar tonsils invariably is present.
Poor visualization of the cisterns and subdural and epidural fluid collections also may be identified.
No additional testing is indicated for a patient who has undergone dural puncture and then develops a classic postural headache, unless infection or subarachnoid hemorrhage is suspected. In this setting, lumbar puncture, complete blood cell count, and erythrocyte sedimentation rate are indicated on an emergent basis.
Differential Diagnosis
If the clinician is aware that the patient has undergone dural puncture, the diagnosis of post dural puncture headache is usually made. Delayed diagnosis most often occurs in settings in which dural puncture is not suspected.
Occasionally, post dural puncture headache is misdiagnosed as migraine headache because of the associated nausea and vomiting coupled with visual disturbance. In any patient with dural puncture, infection remains an ever-present possibility.
If fever is present, immediate lumbar puncture and blood cultures should be obtained and the patient started on antibiotics that cover resistant strains of Staphylococcus . MRI to rule out epidural abscess also should be considered if fever is present. Subarachnoid hemorrhage may mimic post–dural puncture headache but should be identified on MRI of the brain.
Treatment
The mainstay of treatment of post–dural puncture headache is the administration of autologous blood into the epidural space. This technique is known as epidural blood patch and is highly successful in the treatment of post dural puncture headache.
A volume of 12 to 18 mL of autologous blood is injected slowly into the epidural space at the level of dural puncture under strict aseptic precautions. The patient should remain in the horizontal position for the next 12 to 24 hours. Relief occurs within 2 to 3 hours in more than 90% of patients.
Approximately 10% of patients experience temporary relief and then a recurrence of symptoms when assuming the upright position. These patients should undergo a second epidural blood patch within 24 hours.
If the patient has experienced significant nausea and vomiting, antiemetics combined with intravenous fluids help speed recovery.
Some clinicians have advocated the use of alcoholic beverages to suppress the secretion of antidiuretic hormone and increase cerebrospinal fluid production. Caffeine and systemic glucocorticoids also have been reported to be helpful in treating the headache pain.
Complications
Failure to recognize, diagnose, and treat post–dural puncture headache promptly may result in considerable pain and suffering for the patient. If the low cerebrospinal fluid pressure is allowed to persist, cranial nerve deficits may occur.
In most instances, the cranial nerve deficits are temporary, but in rare instances, these deficits may become permanent, especially in patients with vulnerable nerves, such as those with diabetes.
MRI of the brain is indicated in all patients thought to be suffering from headaches associated with dural puncture. Failure to diagnose central nervous system infection correctly can result in significant mortality and morbidity.
Clinical Pearls
The diagnosis of post dural puncture headache is made by obtaining a thorough, targeted headache history and performing a careful physical examination. The postural nature is pathognomonic for post dural puncture headache, and its presence should lead the clinician to strongly consider the diagnosis of post dural puncture headache.
The incidence of post dural puncture headache after lumbar puncture, myelography, or spinal anesthesia can be decreased by using needles with a smaller diameter and placing the needle bevel parallel to the dural fibers. Special noncutting needles may decrease further the incidence of post dural puncture headache
