What are the treatment options for spinal headaches?

Treatment of Spinal Headache (Post-Dural Puncture Headache)

Start with multimodal analgesia (acetaminophen and NSAIDs) combined with oral hydration and caffeine within the first 24 hours; reserve epidural blood patch for moderate-to-severe cases that fail conservative management. 1

Conservative Management (First-Line Treatment)

Pharmacological Interventions

Multimodal analgesia should be offered to all patients unless contraindicated:

• Acetaminophen and NSAIDs form the foundation of pain management (evidence grade: B; level of certainty: low) 1, 2
• Caffeine may be offered in the first 24 hours with a maximum dose of 900 mg per day (200-300 mg if breastfeeding), avoiding multiple sources to prevent adverse effects (evidence grade: B; level of certainty: low) 1, 2, 3
• Short-term opioids may be considered only if multimodal analgesia is ineffective (evidence grade: C; level of certainty: low), but long-term opioid use is not recommended (evidence grade: D; level of certainty: moderate) 1, 2, 3

Supportive Measures

Hydration and positioning strategies:

• Maintain adequate hydration with oral fluids; use intravenous fluids only when oral hydration cannot be maintained (evidence grade: C; level of certainty: low) 1, 2, 3
• Bed rest is not routinely recommended for treatment, though it may be used as a temporizing measure for symptomatic relief (evidence grade: C; level of certainty: low) 1, 2
• Abdominal binders and aromatherapy are not supported by evidence (evidence grade: D; level of certainty: low) 1

Medications NOT Recommended

The following have insufficient evidence and should not be used routinely:

• Hydrocortisone, theophylline, triptans, adrenocorticotropic hormone or cosyntropin, neostigmine or atropine, piritramide, methergine, and gabapentin (evidence grade: I; level of certainty: low) 1, 2

Procedural Interventions (Second-Line Treatment)

Greater Occipital Nerve Blocks

Consider as an intermediate step before epidural blood patch:

• May be offered to patients with PDPH after spinal anesthesia with narrower gauge needles (22G) (evidence grade: C; level of certainty: moderate) 2, 3
• Important caveat: headache may recur in a substantial proportion of patients, potentially requiring epidural blood patch 2
• Efficacy after dural puncture with wider-gauge needles remains unclear (level of certainty: low) 1

Epidural Blood Patch (Definitive Treatment)

Remains the most effective treatment for moderate-to-severe PDPH:

• Reserved for cases not responding to conservative measures 2, 3, 4
• Most effective invasive treatment available, though not without inherent risks 4
• In rare cases where autologous blood poses risk (e.g., disseminated fungal infection, malignancy), allogeneic blood patch from a tested donor may be considered 5

Interventions NOT Recommended

Insufficient evidence supports routine use of:

• Acupuncture for treating PDPH (evidence grade: I; level of certainty: low) 2
• Sphenopalatine ganglion blocks (evidence grade: I; level of certainty: low) 2

Clinical Algorithm for Treatment Escalation

1. Initial presentation: Start multimodal analgesia (acetaminophen + NSAIDs) + oral hydration + caffeine (within 24 hours) 1, 2

2. If inadequate response after 24-48 hours: Add short-term opioids if needed 1, 2

3. Persistent moderate-to-severe symptoms: Consider greater occipital nerve block (particularly after narrow-gauge needle procedures) 2, 3

4. Refractory cases: Proceed to epidural blood patch 2, 3, 4

Red Flags Requiring Immediate Neuroimaging

Obtain brain imaging urgently if any of the following develop:

• Focal neurological symptoms, visual changes, altered consciousness, or seizures (evidence grade: B; level of certainty: moderate) 2, 3
• Non-orthostatic headache pattern 2, 3
• Headache onset more than 5 days after suspected dural puncture (evidence grade: C; level of certainty: low) 2, 3

Common Pitfalls to Avoid

Medication overuse headache prevention:

• Limit acute headache therapy to no more than twice weekly 3
• Educate patients about risks with frequent analgesic use (>15 days/month) or opioids (>10 days/month) 3
• Most PDPH cases are self-limiting and resolve within 1 week without treatment 4

Prophylactic measures are NOT recommended:

• Prophylactic epidural blood patch is not recommended routinely (evidence grade: I; level of certainty: low) 1
• Prophylactic bed rest does not prevent PDPH (evidence grade: D; level of certainty: moderate) 1