What is the recommended management for post‑dural puncture headache?

Management of Post-Dural Puncture Headache

Begin with multimodal analgesia (acetaminophen and NSAIDs) plus caffeine up to 900 mg/day in the first 24 hours, maintain adequate oral hydration, and proceed directly to epidural blood patch if symptoms are severe or fail to improve after 2-3 days. 1, 2

Initial Conservative Management (First 24-48 Hours)

Pharmacological Treatment:

• Offer regular multimodal analgesia with acetaminophen and NSAIDs to all patients unless contraindicated (evidence grade B) 1, 2
• Administer caffeine up to 900 mg per day within the first 24 hours of symptom onset (200-300 mg if breastfeeding) to provide temporary relief (evidence grade B) 1, 2
• Consider short-term opioids only if multimodal analgesia is ineffective (evidence grade C) 1, 2

Supportive Measures:

• Maintain adequate hydration with oral fluids; use intravenous fluids only when oral intake cannot be maintained (evidence grade C) 1, 2
• Bed rest may be used as a temporizing measure for symptomatic relief only, but does not treat or prevent PDPH and should not be routinely prescribed (evidence grade C-D) 1, 2

Procedural Interventions

Epidural Blood Patch (EBP) - Definitive Treatment:

• Perform EBP when symptoms are severe or do not begin to resolve after 2-3 days of dural puncture 3, 4
• EBP achieves success rates exceeding 90% for persistent or severe PDPH, with complete symptom resolution in all patients across large studies 3
• Position the needle at the same interspace as the dural puncture or one level below 3
• Inject 15-20 mL of autologous blood slowly and incrementally; pause if significant backache or headache develops 3, 5
• Approximately 19-20% of patients may require a second EBP 4
• Marked decrease in pain intensity occurs approximately 4 hours after the procedure 3

Alternative Procedural Options:

• Greater occipital nerve blocks may be offered to patients with PDPH after spinal anesthesia with narrower-gauge needles (22G), though headache may recur in a substantial proportion requiring subsequent EBP (evidence grade C, moderate certainty) 1, 2

Treatments to Avoid

The following interventions lack evidence and should NOT be used routinely:

• Sphenopalatine ganglion blocks (evidence grade I, low certainty) 1, 6
• Hydrocortisone, teofilina, triptanes, ACTH, cosintropina, neostigmina, atropina, piritramida, metergina, or gabapentina (evidence grade I, low certainty) 2
• Acupuncture (evidence grade I, low certainty) 2
• Abdominal binders or aromatherapy 3

Red-Flag Features Requiring Urgent Neuroimaging

Obtain brain imaging immediately if any of the following develop:

• Focal neurological deficits, visual disturbances, altered consciousness, or seizures 2, 3
• Transition from orthostatic to non-orthostatic headache pattern 2, 3
• Headache onset more than 5 days after suspected dural puncture 2, 3
• Persistent or worsening symptoms despite epidural blood patch 3

These features may indicate life-threatening complications including subdural hematoma or cerebral venous sinus thrombosis 3

Follow-Up and Long-Term Monitoring

• Continue clinical follow-up until headache has completely resolved 3
• Communicate PDPH diagnosis and management plan to primary care physician and relevant specialists 3
• Monitor for potential long-term complications including chronic headache, backache, cranial nerve dysfunction, subdural hematoma, and cerebral venous sinus thrombosis 1, 3
• If backache persists, worsens, or changes character after EBP, investigate alternative diagnoses 3

Common Clinical Pitfalls

• Do NOT delay EBP when headache is described as "intractable" at 3 days—this represents severe symptoms warranting immediate intervention 3
• Do NOT prescribe bed rest as treatment—there is no evidence it reduces PDPH 1, 3
• Do NOT assume every postoperative headache is PDPH—red-flag features should always trigger consideration of other etiologies 3
• Do NOT discharge patients before full symptom resolution—premature discharge may miss serious complications 3