What is the recommended acetaminophen and caffeine dosage for an adult with a post‑dural puncture headache?

Acetaminophen with Caffeine Dosing for Post-Dural Puncture Headache

For treatment of established post-dural puncture headache, administer acetaminophen 500 mg combined with caffeine 65 mg orally, repeated every 6 hours as needed, with a maximum caffeine dose of 900 mg per day (approximately 13-14 doses), administered within the first 24 hours of symptom onset. 1, 2

Dosing Regimen

• Acetaminophen 500 mg + caffeine 65 mg orally every 6 hours is the evidence-based regimen supported by guideline recommendations 1, 2
• Maximum caffeine dose: 900 mg/day (approximately 13-14 doses of the 65 mg formulation) 1, 2
• Timing is critical: Caffeine should be administered within the first 24 hours of symptom onset for optimal effect 1, 2
• For breastfeeding patients: Reduce caffeine to 200-300 mg per day 2

Expected Clinical Response

• Caffeine provides temporary relief but headache may recur in 30% of patients within 24 hours 3
• Relief typically occurs within 4 hours of administration, but this does not represent definitive treatment 3
• The mechanism addresses cerebral vasoconstriction but does not repair the underlying CSF leak 4

Integration with Multimodal Analgesia

• Always combine with acetaminophen and NSAIDs (unless contraindicated) as first-line multimodal analgesia 1, 2
• Short-term opioids may be added only if multimodal analgesia fails to control pain 2
• Maintain adequate oral hydration; use IV fluids only if oral intake is insufficient 1, 2

Critical Limitations of Caffeine Therapy

• Caffeine does NOT prevent PDPH and has no role in prophylaxis 4, 1
• Caffeine is NOT definitive treatment—it provides symptomatic relief only while the dural tear heals spontaneously or until epidural blood patch is performed 4
• The UK Joint Specialist Societies explicitly list caffeine under "practices NOT proven to reduce risk of post-LP headache" 4

When to Escalate to Epidural Blood Patch

• Proceed to epidural blood patch (EBP) if symptoms are severe or do not begin to resolve after 2-3 days of conservative management 1, 2
• EBP achieves >90% success rate and is the definitive treatment for persistent PDPH 1, 2
• At 3 days with intractable headache, proceed directly to EBP rather than continuing conservative measures 2

Treatments to Avoid

• Bed rest does NOT treat or prevent PDPH (relative risk 0.98 [95% CI, 0.68-1.41]) and should not be prescribed routinely 4, 1
• Increased hydration beyond adequate intake does NOT help (no difference between 1.5L vs 3L post-LP) 4, 1
• Avoid ineffective treatments including abdominal binders, aromatherapy, hydrocortisone, theophylline, and gabapentin 2

Red Flags Requiring Urgent Imaging

• Focal neurological deficits, visual disturbances, altered consciousness, or seizures 2
• Transition from orthostatic to non-orthostatic headache pattern 2
• Persistent or worsening symptoms despite EBP 2
• These may signal subdural hematoma or cerebral venous sinus thrombosis 4, 2

Clinical Pitfall to Avoid

Do not rely on caffeine as definitive therapy—it is a temporizing measure only. The structural CSF leak from dural tear requires either spontaneous healing (which occurs in >85% of cases) or epidural blood patch for persistent symptoms. 4, 2