Is a headache that worsens in the upright position and improves in the supine position common the day after a lumbar puncture (LP)?

Post-Lumbar Puncture Headache: Characteristics and Management

Yes, a headache that worsens in the upright position and improves in the supine position is a common complication occurring the day after a lumbar puncture, affecting up to 35% of patients. 1

Characteristics of Post-Dural Puncture Headache (PDPH)

• PDPH typically has a low-pressure phenotype - worse when upright and better when lying flat 1
• Usually develops within 3 days of the procedure (often the next day) and manifests as an orthostatic or postural headache 1
• The headache is precipitated by moving from a supine to an upright position and resolves within 20 seconds of lying down 1
• It is caused by sustained leakage of cerebrospinal fluid (CSF) from the dural tear created during the lumbar puncture 1
• The leakage leads to transient intracranial hypotension when standing, causing dilation of intracranial veins and triggering meningeal nociceptive terminals 1

Incidence and Risk Factors

• Post-dural puncture headache affects up to 35% of patients following lumbar puncture 1
• The incidence of typical post-LP headache ranges from 0.9% to 9.0% in some studies 1
• Risk factors associated with PDPH include:
  • Younger age 2
  • Previous history of headache 2
  • Female gender (higher incidence and greater intensity) 2
  • Use of conventional (cutting) needles rather than atraumatic (pencil-point) needles 1
  • Larger needle gauge 1
  • Multiple attempts at dural puncture 1

Management of Post-LP Headache

• More than 85% of post-LP headaches resolve without treatment 1
• For mild cases:
  • Caffeine or paracetamol/caffeine can be used for symptomatic relief 1
  • Note that while caffeine may treat symptoms, there is no evidence that it prevents the headache 1
• For severe and persistent headache:
  • Epidural blood patch is the most effective treatment 1, 3
  • This involves injection of 10-20 ml of autologous blood into the epidural space at the site of the dural puncture 3
  • It is effective (leading to complete recovery) and well-tolerated in all age ranges 1

Prevention Strategies

• Use of atraumatic (pencil-point) needles significantly reduces the risk of PDPH 1
• Smaller gauge needles reduce risk, though this needs to be balanced with procedure duration (22G is often practical) 1
• Orientation of the bevel of the needle in a transverse plane (perpendicular to the longitudinal axis) 1
• Replacement of the stylet before withdrawing the needle 1
• Fewer attempts at dural puncture 1

Common Misconceptions About Prevention

• There is no evidence that the following practices reduce the risk of post-LP headache:
  • Reducing the volume of CSF taken 1
  • Bed rest after the procedure 1
  • Increased hydration (studies show no difference between 1.5L vs 3L fluid intake post-LP) 1
  • Prophylactic use of caffeine 1

Potential Complications

• Rarely, persistent low pressure from CSF leak may be associated with the development of subdural hematomas 1
• Other very rare but potentially serious complications include cerebral or spinal hemorrhage, spinal epidural hematoma, and cerebral venous thrombosis (occurring in <1 in 10,000 patients) 1
• Some patients who receive epidural blood patches for PDPH may have an increased risk of subsequent chronic low back pain 4

In conclusion, the orthostatic headache you're describing is a classic presentation of post-dural puncture headache, which is indeed common following lumbar puncture. While most cases resolve spontaneously within a week, severe cases may require more aggressive management with an epidural blood patch.