Management of Spinal Headaches
Epidural blood patch is the most effective treatment for moderate to severe postdural puncture headaches that do not respond to conservative management within 24-48 hours. 1
Initial Conservative Management
For mild to moderate postdural puncture headaches, conservative measures should be implemented first:
Analgesia
- Regular multimodal analgesia should be the first-line treatment 1, 2:
- Acetaminophen 500-1000 mg every 6-8 hours
- NSAIDs (if not contraindicated): ibuprofen 400-600 mg every 6-8 hours
Caffeine
- Offer caffeine during the first 24 hours of symptoms 1, 2, 3:
- Maximum dose: 900 mg/day (200-300 mg if breastfeeding)
- Avoid multiple sources to prevent adverse effects
- Mechanism: Causes cerebral vasoconstriction, counteracting the vasodilation associated with low CSF pressure
Hydration
- Maintain adequate hydration with oral fluids 1, 2
- Use intravenous fluids only when oral hydration is not possible
- Note: No difference in outcomes between 1.5L vs 3L fluid intake post-lumbar puncture 2
Positioning
- Bed rest is not routinely recommended but may provide temporary symptomatic relief 1, 2
- Patient may find lying flat more comfortable as symptoms are typically positional
Short-term Opioids
- Consider short-term opioids only if multimodal analgesia is ineffective 1
- Long-term opioid use is not recommended due to risk of dependency and rebound headaches 1
Interventional Management
If conservative measures fail after 24-48 hours or symptoms are severe:
Epidural Blood Patch (EBP)
- First-line interventional treatment for moderate-to-severe PDPH 1, 4
- Most effective treatment with success rates of 70-90% after first application
- Technique: Autologous blood injected into epidural space at or below the level of dural puncture
- Timing: Consider after 24-48 hours of failed conservative management
- Note: Prophylactic EBP is not recommended as routine practice 1
Other Interventional Options (Limited Evidence)
- Greater occipital nerve blocks: May be considered for PDPH after spinal anesthesia with narrower-gauge needles (≤22G), but headache may recur 1
- Epidural saline: May provide temporary benefit but not long-lasting relief 1
- Fibrin glue: Reserved only for PDPH refractory to EBP or when autologous blood injection is contraindicated 1
Interventions NOT Recommended
Evidence does not support routine use of:
- Bed rest for prophylaxis 1
- Abdominal binders or aromatherapy 1
- Acupuncture 1
- Sphenopalatine ganglion blocks 1
- Spinal/epidural morphine 1, 5
- Epidural dextran, gelatin, or hydroxyethyl starch 1
- Hydrocortisone, theophylline, triptans, ACTH, neostigmine, atropine, piritramide, methergine, or gabapentin 1
Imaging Considerations
- Imaging is typically not indicated for suspected postdural puncture headache within 72 hours of dural puncture 1
- Consider brain imaging only when:
- Headache has non-orthostatic features
- Headache onset is more than 5 days after dural puncture
- Focal neurological deficits, visual changes, altered consciousness, or seizures are present 1
Prevention Strategies
- Use smaller caliber needles (22G or smaller) 1, 2
- Use non-cutting (atraumatic) needles 1, 2
- Orient needle bevel in transverse plane 2
- Replace stylet before withdrawing needle 2
- Minimize number of puncture attempts 1, 2
- Consider lateral decubitus position for procedure 1, 2
Clinical Course
- Most postdural puncture headaches are self-limiting and resolve within 1 week without treatment 4
- If symptoms persist beyond 1 week or worsen, reevaluation is necessary to rule out other causes
Common Pitfalls to Avoid
- Delaying epidural blood patch in patients with severe, debilitating symptoms
- Overuse of opioids leading to dependency or rebound headaches
- Failing to consider alternative diagnoses when headache characteristics change or neurological symptoms develop
- Routine use of prophylactic measures without evidence of benefit