What is the recommended treatment protocol for a post‑spinal anesthesia (post‑dural puncture) headache?

Post-Spinal Anesthesia Headache Treatment Protocol

Begin with conservative management for the first 24-48 hours, then proceed to epidural blood patch if symptoms are severe or fail to improve by 2-3 days post-procedure. 1, 2

Initial Conservative Management (First 24-48 Hours)

Offer multimodal analgesia with acetaminophen and NSAIDs to all patients unless contraindicated (evidence grade B). 1, 2 This forms the foundation of initial symptom control and should be started immediately upon diagnosis. 2

Administer caffeine up to 900 mg per day (200-300 mg if breastfeeding) within the first 24 hours of symptom onset (evidence grade B). 1, 2 Caffeine provides temporary relief but avoid multiple sources to prevent adverse effects. 3

Maintain adequate oral hydration; reserve intravenous fluids for patients unable to maintain oral intake (evidence grade C). 1, 2 While hydration does not prevent PDPH, maintaining adequate fluid intake is reasonable supportive care. 2

Consider short-term opioids only when multimodal analgesia fails to control pain (evidence grade C). 1, 2 Avoid long-term opioid use. 2

Critical Pitfall to Avoid

Do NOT prescribe bed rest as a therapeutic measure—there is no evidence it reduces headache severity, though it may be used temporarily for symptomatic relief only (evidence grade C-D). 1, 2 Bed rest does not prevent or treat PDPH and should not be routinely recommended. 1

Treatments to Avoid (Ineffective)

Do NOT use the following interventions, as evidence does not support their effectiveness (evidence grade I-D): 1, 2

• Abdominal binders
• Aromatherapy
• Systemic hydrocortisone
• Theophylline
• Gabapentin
• Triptanes
• Sphenopalatine ganglion blocks 2

Procedural Interventions

Epidural Blood Patch (EBP): Definitive Treatment

Perform an EBP when PDPH is refractory to conservative therapy and impairs activities of daily living, or when symptoms are severe or fail to begin resolving after 2-3 days (evidence grade B). 1, 2 This represents the threshold for definitive intervention. 2

EBP should also be considered for patients with severe neurological symptoms such as hearing loss or cranial neuropathies (evidence grade C). 1

Expected Success Rates

EBP achieves complete headache remission in 33-91% of patients, with success rates exceeding 90% in persistent or severe PDPH. 1, 2 More than 85% of post-spinal headaches resolve spontaneously, but patients with severe or worsening symptoms at 2-3 days require intervention. 2

Technical Performance of EBP

Position the needle at the same interspace as the dural puncture or one level below (evidence grade B). 1, 2

Maintain strict aseptic technique for both blood draw and epidural injection (evidence grade B). 1, 2

Inject 15-20 mL of autologous blood slowly and incrementally; pause if the patient develops significant backache or headache and resume once symptoms subside. 1, 2 Injection of more than 30 mL does not increase success rates. 1

Expect a marked decrease in pain intensity approximately 4 hours after the procedure. 2, 4

Timing Considerations

If EBP is performed within 48 hours of dural puncture, counsel patients about a more likely need for repeat EBP to achieve symptom resolution (evidence grade B). 1

Alternative Approaches

Consider fluoroscopically guided transforaminal EBP in cases of prior laminectomy near the dural puncture site or after unsuccessful interlaminar EBP (evidence grade C). 1 Fluoroscopic guidance may allow successful treatment with smaller blood volumes (mean 7.2 mL). 5

Alternative Procedural Option

Greater occipital nerve blocks may be offered to patients with PDPH after spinal anesthesia with narrow-gauge needles (≈22 G) (evidence grade C, moderate certainty). 1, 2 However, headache may recur in a substantial proportion of patients, ultimately requiring EBP. 1, 2

Red-Flag Features Requiring Urgent Neuroimaging BEFORE EBP

Obtain urgent brain imaging and specialist referral if any of the following are present: 2, 4

• Focal neurological deficits, visual disturbances, altered consciousness, or seizures 2
• Transition from orthostatic to non-orthostatic headache pattern 2, 4
• Emergence of new symptoms after initial presentation 2
• Persistence or worsening despite prior EBP 2
• Headache onset more than 5 days after suspected dural puncture 2

These features may signal life-threatening complications such as subdural hematoma or cerebral venous sinus thrombosis. 2, 4

Contraindications and Precautions for EBP

Follow appropriate guidelines regarding neuraxial injection in patients receiving antithrombotics or with low platelet counts (evidence grade B). 1

Exercise caution in febrile patients or those with systemic signs of infection; deferring the procedure may be appropriate if there is risk of hematogenous infection (evidence grade C). 1

Do NOT routinely obtain blood cultures before EBP (evidence grade D). 1

Follow-Up and Long-Term Monitoring

Continue clinical follow-up until the headache has completely resolved. 2 Regular patient follow-up should determine the need for repeat EBP in cases suggestive of persistent or severe CSF leak (evidence grade C). 1

Monitor for long-term complications including: 2, 4

• Chronic headache
• Persistent back pain
• Cranial nerve dysfunction
• Subdural hematoma
• Cerebral venous sinus thrombosis

If back pain persists, worsens, or changes character after EBP, investigate alternative diagnoses. 2

Communicate the PDPH diagnosis and management plan to the patient's primary care physician and relevant specialists. 2