What are the causes of headache after lumbar puncture (LP)?

From the Guidelines

Post-lumbar puncture headache is primarily caused by the leakage of cerebrospinal fluid through the dural defect into the epidural space, resulting in low pressure in the brain, as supported by the most recent evidence from 1. The leakage of cerebrospinal fluid is attributed to the type of needle used, with conventional needles having a higher risk of causing post-dural-puncture headache due to their sharp tip and distal opening, as compared to atraumatic needles which have a blunt tip and side port for injection or collection, as noted in 1 and 1. Some key factors that contribute to the development of post-lumbar puncture headache include:

• The use of larger gauge needles, as mentioned in 1
• Multiple attempts at dural puncture, as highlighted in 1
• The use of a cutting needle versus a pencil-point tip needle, as discussed in 1
• Needle orientation perpendicular rather than parallel to the spine longitudinal axis, as noted in 1
• Dural puncture in the sitting position as opposed to lateral decubitus positioning, as mentioned in 1 It is essential to note that post-lumbar puncture headaches can be managed with conservative approaches, and prevention strategies such as using smaller gauge needles and maintaining hydration before and after the lumbar puncture can help reduce the risk of developing this complication, as suggested by 1, 1, and 1.

From the Research

Causes of Headache after Lumbar Puncture (LP)

The causes of headache after lumbar puncture (LP) can be attributed to several factors, including:

• Needle size and type: The use of smaller gauge needles, particularly those with an atraumatic tip, can reduce the incidence of post-dural puncture headache (PDPH) 2, 3, 4
• Needle bevel orientation: Ensuring the bevel is aligned parallel to the longitudinal fibers of the dura can minimize the risk of headache 3
• CSF leakage: The leakage of cerebrospinal fluid (CSF) from the dural puncture site can lead to a state of low sub-arachnoid pressure, causing traction on pain-sensitive intracerebral structures 3, 4
• Patient characteristics: Younger women with a previous history of headaches appear to be at highest risk of developing PDPH 2

Pathophysiology of Post-Dural Puncture Headache

The pathophysiology of PDPH is thought to be related to the leakage of CSF from the subarachnoid to the epidural spaces, resulting in a low-pressure headache 4. This can cause traction on pain-sensitive intracerebral structures, leading to the characteristic symptoms of PDPH, including:

• Postural headache
• Nausea
• Vomiting
• Tinnitus
• Ocular disturbances 5, 2, 6

Risk Factors for Post-Dural Puncture Headache

Several risk factors have been identified for the development of PDPH, including:

• Younger age (< 50 years) 2, 4
• Female sex 2
• Previous history of headaches 2
• Use of large-gauge needles 4
• Post-partum status 4