Post Lumbar Puncture Headache
Post Lumbar Puncture Headache
The proper terminology is "Post-Dural Puncture Headache", as the condition can be caused after deliberate puncture eg Lumbar Puncture or inadvertent puncture eg complicating an epidural procedure.
The typical feature is called a Postural Headache.
To meet criteria for reserach the postural headache must begin or terminate within 15 minutes of standing or lying.
However, one study reported that 50% of postural headaches have onset within 20 seconds of rising, and 50% resolve within 30 seconds of lying down again.
What are Symptoms of Post Lumbar Puncture headache?
To be attributed to lumbar puncture it must have started within 5 days, and have either resolved within a week or been resolved by epidural blood patch.
The pain can be anywhere in the head. I've seen it in occipital, frontal and temporal locations, but the pain is usually bilateral.
It can radiate into the upper spine or between shoulder blades.
There are cases of isolated thoracic pain in the literature which resolved following epidural blood patching.
Pain can feel throbbing, but some just report a bad dull ache.
Nausea, which is worse when upright is fairly common and can occur in the absence of headache.
Ear symptoms are very common - muffling of noise, tinnitus or even deafness.
Double vision can occur if the IVth or VIth cranial nerves are compromised by low pressure along thier long intracranial courses.
Physical activity worsens the headache eg coughing and sneezing, not just erect posture.
Who is at risk of Post-Lumbar Puncture Headache?
Women have double the risk of men.
Younger people and people with recent other headaches are more likely to experience a post lumbar puncture headache.
A 20 year old has almost 5 times the chance than a 60 year of developing this problem.
Obesity reduces the risk of post-LP headache.
This may be due to greater difficulty in needle insertion, therefore causing more trauma at the site of puncture, so less likely to cause a CSF leak.
It could also be due to the fact that obese individuals generally have a higher than average CSF pressure, so it is more difficult for them to experience a situation of low pressure.
The Importance of Needle Selection
The main risk factor of Post-Lumbar Puncture Headache is the type of needle used.
There is now good evidence that an atraumatic needle should be used for diagnostic lumbar puncture.
The diamater (gauge) is also a factor - finer needles are less likely to cause the problem.
An overall post-LP headache rate of 10% should be quoted if this needle type is used.
For classic, cutting needles (traumatic type), the angle of needle insertion and orientation of the bevelled tip can influence risk of post-LP headache. An inexperienced operator is more likely to have their patient experience a PLPH.
There is a 50% post-LP headache rate with traumatic needle type.
A survey of neurologists in the early 2000s found that almost 50% of neurologists in the US had not heard of atraumatic needles which were developed by anaesthesiologists. There is now a concerted effort to implement use of these needles, as 39% of people with these headache will experience at least a week of significant functional impairment.
The Onset and Duration of Post Lumbar Puncture Headache
Of 239 people who had a lumbar puncture 89 (36%) developed post lumbar puncture headache. 50% had onset within 14 hours, and by day 2 89% had onset. Nobody in that series had onset after day 4.
In the same study the pain lasted for an average of 6 days, although 2 cases had headaches for 3-4 weeks.
In an older study, long term low pressure headache could still persist up to 6 months. Subsequent studies have found people who respond to epidural blood patching months or years following their lumbar puncture procedure.
Treatment of Headache after Lumbar Puncture
A pre-emptive epidural blood patch at the time of lumbar puncture might be effective, but there is no consensus on this.
At least 50% are better within 4 days, so the initial management is rest and painkillers.
Increased fluid is often advised, but the evidence that it works has either never been sought, or was never reported.
Disabling headache at 7 days should be considered for an >strong>epidural blood patch procedure.
Intravenous Theophylline has some evidence to support its use, but is limited by toxicity.
The treatment of choice is an epidural blood patch.
The first blood patch reported by Gormley used only 2-3ml of blood.
Nowadays up to 30ml might be injected. A randomised trial showed that 42% of treated compared to 10% of untreated post lumbar puncture headache were relieved by epidural blood patch within 24 hours.
Injection of blood is limited by nerve root pain. If radicular pain is experienced the injection should be terminated.
The blood travels within the spinal canal - on average 6 spinal segments towards the head, and 3 towards the feet.
The blood probably reduces headache by increasing compliance of the spinal compartment.
This increased spinal compartment compliance gives greater support to the intracranial contents and relieves the effect of low pressure.
There may be some truth in the notion that injecting blood will "seal off" a CSF leak, as on imaging studies, a clot is detectable over the posterior surface of the dural sac at 7-13 hours post-patch.
It is usual practice to lie recumbent for 1-2 hours after a blood patch.
I will not go into the technique of blood patching, except to say that a complication is inadvertent injection of air or blood into the subarachnoid sapce causing pneumocephalus or an iatrogenic subarachnoid haemorrhage.
If not a Post Lumbar Puncture Headache what else could it be?
If a headache persists after epidural blood patch, the following diagnoses should be considered, especially in women who are post-partum:
- Cortical Vein Thrombosis
- Cerebral Venous Sinus Thrombosis
- Sybdural Haematoma
- Intracerebral haemorrhage
- Pituitary Apoplexy
- Chemical or Bacterial Meningitis
Occipital nerve block is known to help many different types of headache and post-lumbar puncture headache is one of those too.
If you are following the Online LP Training Module Return to Email 2
Please try to prevent Post Lumbar Puncture Headache. Read more about the LP Procedure.
Severe Headache Expert Home Page