What does an orbital and temporal headache indicate in a patient who has recently undergone spinal anesthesia?

Orbital and Temporal Headache After Spinal Anesthesia

In a patient who has recently undergone spinal anesthesia, orbital and temporal headache most likely indicates post-dural puncture headache (PDPH), which occurs in 2-8% of cases and typically develops within the first 5 days after the procedure. 1, 2

Primary Diagnosis: Post-Dural Puncture Headache

The key diagnostic feature is whether the headache is postural (orthostatic) - worsening when upright and improving when lying down. 2 This postural characteristic distinguishes typical PDPH from more serious complications. 2

Typical PDPH Presentation

• Onset within 5 days of spinal anesthesia (most commonly within first 48-72 hours) 2, 3
• Postural/orthostatic pattern - worse upright, better supine 1, 2
• Often accompanied by neck stiffness and/or auditory symptoms 2
• Can be severe enough to interfere with daily activities 2

Natural History

• More than 85% of PDPH cases resolve spontaneously without treatment 2, 3
• Most resolve within 2 weeks, though severity varies 2

Critical Red Flags Requiring Urgent Evaluation

You must immediately consider life-threatening complications if the headache has ANY of these atypical features:

Loss of Postural Character

If the headache becomes non-orthostatic or loses its postural pattern, this suggests intracranial subdural hematoma rather than simple PDPH. 4, 5, 6 This represents a neurosurgical emergency requiring immediate brain imaging. 4, 5

Specific Warning Signs for Subdural Hematoma

• Headache that initially was postural but then becomes constant (no longer relieved by lying down) 4, 5
• Onset more than 5 days after the procedure 2
• New neurological deficits (though headache may be the only initial symptom) 6
• Progressive worsening despite conservative management 4, 5

The mechanism is CSF leakage causing intracranial hypotension, which leads to downward brain sagging and tearing of bridging veins, resulting in subdural hematoma. 4, 5, 6

Management Algorithm

Within First 72 Hours with Typical Postural Headache

Conservative management is appropriate initially: 2

• Maintain adequate oral hydration 2
• Multimodal analgesia: acetaminophen and NSAIDs (unless contraindicated) 2
• Caffeine up to 900 mg/day may be offered in first 24 hours 2
• Short-term opioids only if multimodal analgesia fails 2

Do NOT prescribe bed rest - there is no evidence it helps. 2

At 2-3 Days with Severe or Non-Resolving Symptoms

Proceed directly to epidural blood patch (EBP) if symptoms are severe or not beginning to resolve by 2-3 days post-procedure. 1, 2 This is the definitive treatment with over 85% success rate. 2

• EBP should be performed at the level of the original dural puncture 2
• Marked pain reduction occurs within 4 hours of the procedure 2
• Complete recovery occurs in patients who receive EBP 2

Imaging Indications

Imaging is NOT typically indicated for typical PDPH within 72 hours of dural puncture, as these headaches are self-limited and managed conservatively. 1

However, brain imaging (MRI head with and without contrast preferred) is mandatory when: 1

• Headache onset more than 5 days after spinal anesthesia 2
• Non-orthostatic headache or loss of postural character 2, 4, 5
• Any new neurological symptoms 4, 5, 6
• Headache location changes from typical occipital to frontal/orbital/retroorbital (may indicate rebound headache if post-blood patch, or subdural hematoma) 1

Special Consideration: Rebound Headache

If the orbital/temporal headache occurs AFTER epidural blood patch treatment, consider rebound headache from elevated CSF pressure. 1 This presents with:

• Reversal of orthostatic symptoms (relief upright, worse lying down) 1
• Headache location shift from occipital to frontal/periorbital/retroorbital 1
• Nausea, vomiting, blurry vision 1
• Usually self-limited and managed conservatively 1
• Acetazolamide may be prescribed to lower CSF production 1

Do NOT mistake rebound headache for refractory PDPH and repeat the blood patch, as this will worsen the condition. 1

Bottom Line

Orbital and temporal headache after spinal anesthesia is PDPH until proven otherwise, but you must actively exclude subdural hematoma by confirming the headache maintains its postural character and occurs within the expected 5-day timeframe. 1, 2, 4, 5 Any deviation from typical PDPH features mandates urgent brain imaging to rule out life-threatening intracranial hemorrhage. 4, 5, 6