How to manage a post-lumbar puncture (LP) headache that persists after the first epidural blood patch treatment?

From the Guidelines

For post-lumbar puncture headaches that persist after the first epidural blood patch treatment, it is crucial to first consider the possibility of rebound headaches, which can occur in about a quarter of patients, before proceeding with further interventions. Rebound headaches are characterized by a postprocedural elevation in CSF pressure, usually occurring within the first 1 to 2 postprocedural days, and can include a development of a phenotypically new headache with characteristic reversal of a patient’s preprocedural orthostatic symptoms 1.

Key Considerations

• The clinical syndrome of rebound headaches can include relief of headache in the upright position and exacerbation of symptoms in the recumbent position, along with nausea, emesis, and blurry vision.
• Rebound headaches are usually self-limited and minor and can be managed conservatively with acetazolamide, which lowers CSF production, to ameliorate symptoms.
• CSF drainage via lumbar puncture or lumbar drain can be used in more severe cases that are refractory to medical management.

Management Approach

• Conservative management should be the initial approach for suspected rebound headaches, including the use of acetazolamide.
• If the headache does not respond to conservative management and is not characteristic of a rebound headache, a second epidural blood patch may be considered, although the provided evidence does not directly support this as the next step after a first blood patch failure in the context of managing post-lumbar puncture headaches.
• It is essential to recognize the clinical features of rebound headache to avoid unnecessary imaging or repeat procedures that could raise CSF pressure further and exacerbate the condition 1.

Additional Interventions

• In cases where rebound headache is ruled out and symptoms persist, further evaluation and consultation with a neurologist may be necessary to consider other causes or advanced interventions.
• The use of abdominal binders, strict bed rest, adequate hydration, caffeine supplementation, and analgesics like acetaminophen or NSAIDs may provide additional relief while managing the headache conservatively.

From the Research

Management of Post-Lumbar Puncture Headache Refractory to First Blood Patch Treatment

• The management of post-lumbar puncture headache that persists after the first epidural blood patch treatment involves several considerations, including the effectiveness of the initial treatment and the potential need for alternative or additional interventions 2, 3, 4, 5, 6.
• If the first epidural blood patch is unsuccessful, it is essential to reassess the diagnosis and consider radiographic confirmation of a cerebral spinal fluid leak, as well as identification of its location to direct further therapy 2.
• Alternative treatments that have been reported to be effective in some cases include epidural saline infusion, which can be used alone or in combination with a second epidural blood patch 3.
• The effectiveness of epidural blood patch treatment can be influenced by various factors, including the diameter of the needle used for dural puncture and the delay between dural puncture and treatment 6.
• In some cases, a second epidural blood patch or alternative treatments may be necessary to achieve complete relief of symptoms 3, 6.

Considerations for Treatment

• Epidural blood patch is a common and effective treatment for post-dural puncture headache, but its effectiveness can vary depending on individual factors 4, 6.
• The use of epidural saline infusion as an alternative or adjunctive treatment has been reported in some cases, with varying degrees of success 3.
• The management of post-lumbar puncture headache should be individualized, taking into account the specific circumstances of the patient and the effectiveness of initial treatments 2, 3, 4, 5, 6.

Potential Next Steps

• If the first epidural blood patch is unsuccessful, consider radiographic evaluation to confirm the diagnosis and identify the location of any cerebral spinal fluid leak 2.
• Alternative treatments, such as epidural saline infusion, may be considered in cases where the initial epidural blood patch is ineffective 3.
• A second epidural blood patch or other interventions may be necessary to achieve complete relief of symptoms in some cases 3, 6.