What is the recommended dose of caffeine for a patient with suspected low-pressure headache 2 days post Posterior Lumbar Interbody Fusion (PLIF) at L3/4 and L4/5?

Caffeine Dosing for Post-PLIF Low-Pressure Headache

The evidence does not support using caffeine tablets for post-dural puncture headache, as guideline-level evidence explicitly states caffeine has not been proven to prevent or treat this condition. 1

Critical Evidence Against Caffeine Use

The UK Joint Specialist Societies explicitly lists caffeine under "Practices NOT proven to reduce risk of post LP headache," noting that while some experiments have examined IV caffeine to treat post-LP headache, there is no evidence that either oral or IV caffeine can prevent the headache. 1

However, if you still choose to use caffeine despite lack of evidence, historical case reports have used 500 mg IV caffeine sodium benzoate in 1 liter of fluid over 1.5 hours for post-lumbar puncture headache. 2

What Actually Works: Recommended Management

Conservative Management (First-Line)

• Lying flat is reasonable for symptom relief (though it does not prevent the headache from occurring). 1, 3
• The headache is typically self-limiting in most cases. 1
• The low-pressure phenotype (worse upright, better lying flat) is caused by dural tear, not CSF volume removed. 1

Definitive Treatment When Conservative Fails

• Epidural blood patch is the definitive treatment for persistent post-dural puncture headache. 1
• Blood patch should be prioritized if symptoms persist or are severe. 1

Important Clinical Pitfalls

What Does NOT Work (Evidence-Based)

• Bed rest does NOT prevent post-LP headache (relative risk 0.98 [95% CI, 0.68–1.41]). 3
• Increased hydration does NOT help (no difference between 1.5L vs 3L post-LP). 1, 3
• Reducing CSF volume does NOT influence headache incidence. 1, 3

Serious Complications to Monitor

• Rarely, low pressure may be associated with subdural hematomas—monitor for sudden change in headache pattern or new neurological signs. 1
• Consider imaging if headache character changes or neurological examination changes. 1

Why Caffeine Lacks Evidence in This Context

While caffeine has proven benefit as an analgesic adjuvant for primary headache disorders (migraine and tension-type headache at doses of 100-130 mg), 1, 4 this mechanism is fundamentally different from post-dural puncture headache, which is a structural CSF leak problem, not a primary headache disorder. 1

The single case report showing benefit used IV caffeine sodium benzoate 500 mg, not oral tablets, and this represents the lowest level of evidence. 2

Bottom Line Recommendation

Do not use oral caffeine tablets—the evidence does not support this intervention. 1 Instead, recommend lying flat for symptomatic relief and prepare for epidural blood patch if symptoms persist beyond 24-48 hours or are severe. 1