How should a postoperative headache that begins after anesthesia be evaluated and managed, including assessment for post‑dural puncture headache?

Postoperative Headache After Anesthesia: Evaluation and Management

A postoperative headache developing after neuraxial anesthesia should be immediately evaluated for post-dural puncture headache (PDPH), which presents as a postural headache within the first 5 days after the procedure and requires systematic assessment followed by conservative management initially, with epidural blood patch reserved for severe or persistent cases beyond 2-3 days. 1

Initial Clinical Assessment

Key Diagnostic Features of PDPH

The hallmark of PDPH is its postural nature: the headache worsens when upright and improves within seconds of lying flat. 1, 2 This distinguishes it from other postoperative headaches and is the single most important diagnostic feature.

Additional characteristic features include:

• Onset within 5 days of the neuraxial procedure (spinal anesthesia, epidural, or lumbar puncture) 1
• Neck stiffness accompanying the headache 1, 3
• Subjective auditory symptoms such as tinnitus or hearing changes 1, 3
• Severity that interferes with daily activities 1

Critical Red Flags Requiring Urgent Neuroimaging

Do NOT assume all postoperative headaches are benign PDPH. Urgent neuroimaging and specialist referral are mandatory for: 1

• Worsening symptoms despite epidural blood patch 1
• New focal neurologic symptoms (visual disturbances, altered consciousness, seizures, cranial nerve deficits) 1, 2
• Change in headache character from postural to non-postural pattern 1, 2
• Headache onset more than 5 days after the procedure 2

These features may indicate life-threatening complications including subdural hematoma or cerebral venous sinus thrombosis. 1, 2

Management Algorithm

First 24-48 Hours: Conservative Management

All patients with suspected PDPH should receive multimodal conservative therapy initially: 2, 4

1. Multimodal analgesia (evidence grade B):

   • Acetaminophen and NSAIDs unless contraindicated 2, 4
   • Short-term opioids only if multimodal analgesia fails 2
   • Avoid long-term opioid use 2

2. Caffeine administration (evidence grade B):

   • Up to 900 mg per day within the first 24 hours of symptom onset 2, 4
   • Reduce to 200-300 mg if breastfeeding 2

3. Adequate hydration (evidence grade C):

   • Maintain oral fluid intake 2, 4
   • Use intravenous hydration if oral intake is insufficient 2

Treatments to AVOID (No Evidence of Benefit)

Do NOT prescribe the following, as they are ineffective: 2, 4

• Bed rest (does not prevent or treat PDPH; may be used only for temporary symptomatic relief) 2, 4
• Abdominal binders 2
• Aromatherapy 2
• Systemic hydrocortisone 2
• Theophylline 2
• Gabapentin 2

Days 2-3: Reassessment

If symptoms are severe or do not begin to resolve after 2-3 days, proceed directly to epidural blood patch. 2 This timeframe represents the threshold for definitive intervention. 2

Definitive Treatment: Epidural Blood Patch (EBP)

EBP is the most effective treatment for PDPH with a success rate exceeding 90%. 2, 4 Complete recovery occurs in patients who receive EBP across all age ranges. 2

Indications for EBP:

• Severe symptoms at presentation 2
• Symptoms not resolving after 2-3 days of conservative management 2
• Intractable headache interfering with activities of daily living 2

Technical Considerations:

• Position the needle at the same interspace as the dural puncture or one level below 2
• Maintain strict aseptic technique 2
• Inject 15-20 mL of autologous blood slowly and incrementally 1, 2
• Pause injection if significant backache or headache develops; resume when symptoms subside 1, 2
• Effectiveness is evident by marked decrease in pain approximately 4 hours after the procedure 2, 3

Informed Consent Elements:

• Risk of repeat dural puncture 2
• Risk of post-procedure backache 2

Alternative Interventions (Limited Evidence)

Greater occipital nerve block may be offered after spinal anesthesia with narrower-gauge needles (evidence grade C), though headache may recur in a substantial proportion of patients, ultimately requiring EBP. 2, 4

Epidural saline may provide temporary benefit but should not be expected to provide long-lasting relief. 2

Follow-Up and Long-Term Monitoring

Mandatory Follow-Up Requirements

Continue clinical follow-up until the headache has fully resolved. 1 This is non-negotiable, as PDPH is associated with serious long-term complications. 1

Before Discharge:

• Convey information about PDPH sequelae to patients 1
• Provide contact information for the anesthesiologist and other healthcare practitioners 1
• Ensure other specialties and primary care physicians are informed of PDPH management and potential for long-term symptoms 1

After Discharge:

• Primary care physician may continue follow-up with clear communication about PDPH diagnosis 1
• Refer to pain or neurology specialist if indicated 1

Monitoring for Complications

PDPH is associated with potentially serious long-term complications: 1, 2

• Chronic headache 1, 2
• Backache 1
• Cranial nerve dysfunction 1
• Subdural hematoma 1
• Cerebral venous sinus thrombosis 1

If backache persists, worsens, or changes character after EBP, investigate alternative diagnoses. 1, 2

Common Clinical Pitfalls

1. Delaying EBP in patients with intractable symptoms at 3 days: Do not wait for spontaneous resolution when symptoms are severe. 2

2. Prescribing bed rest as treatment: There is no evidence it reduces PDPH; it only provides temporary symptomatic relief. 2, 4

3. Assuming all postoperative headaches are PDPH: Always consider alternative diagnoses, especially if red flag features are present. 1, 2

4. Inadequate follow-up: Failure to monitor until complete resolution may miss serious complications. 1

5. Not communicating with primary care: The primary care physician must be informed of the PDPH diagnosis and management plan for appropriate long-term monitoring. 1