How should I treat an adult who developed a post‑dural puncture headache that worsens when upright and improves when lying supine?

Treatment of Post-Dural Puncture Headache

Begin multimodal analgesia with acetaminophen and NSAIDs immediately, add oral caffeine up to 900 mg/day within the first 24 hours, and proceed directly to epidural blood patch if symptoms remain severe or fail to improve after 2–3 days. 1, 2

Initial Conservative Management (First 24–48 Hours)

Offer multimodal analgesia with acetaminophen and NSAIDs to all patients unless contraindicated (evidence grade A). 3, 1, 2 This forms the foundation of symptomatic relief and should be initiated immediately upon diagnosis.

Administer oral caffeine up to 900 mg per day (or 200–300 mg if breastfeeding) within the first 24 hours of symptom onset. 1, 2 Caffeine provides temporary relief by causing cerebral vasoconstriction and may reduce headache severity, though symptoms often recur after the effect wears off. 4

Maintain adequate oral hydration; reserve intravenous fluids only for patients unable to maintain oral intake. 1, 2 While hydration does not prevent or cure PDPH, it provides reasonable supportive care. 1

Use short-term opioids only when multimodal analgesia fails to control pain. 1, 2 Avoid long-term opioid prescriptions for this self-limited condition.

Critical Pitfall to Avoid

Do NOT prescribe bed rest as a therapeutic measure. 1, 2 While lying flat provides symptomatic relief while the patient is supine, bed rest does not reduce headache duration or severity and has no role in treatment (evidence grade C-D). 1, 2 Patients may lie flat for comfort, but this should not be prescribed as therapy.

Definitive Treatment: Epidural Blood Patch

Perform an epidural blood patch when PDPH is severe, refractory to conservative measures, or fails to improve after 2–3 days. 1, 2 At this threshold, the patient represents the minority (approximately 15%) who will not resolve spontaneously and requires definitive intervention. 1

Success Rates and Outcomes

• EBP achieves complete headache resolution in >90% of patients with persistent or severe PDPH. 1, 2
• All patients in large multicenter studies achieved complete recovery after EBP. 1
• More than 85% of PDPH cases resolve without treatment, but worsening or severe symptoms at 2–3 days indicate the need for intervention. 1

Technical Procedure Details

Position the needle at the same interspace as the original dural puncture or one level below, using strict aseptic technique. 1, 2 This targeting maximizes the likelihood of sealing the CSF leak.

Inject 15–20 mL of autologous blood slowly and incrementally. 2 Pause the injection if the patient develops significant back pain or headache, then resume once symptoms subside. 1, 2 Volumes exceeding 30 mL do not improve success rates. 2

If EBP is performed within 48 hours of dural puncture, counsel patients that a repeat procedure may be required. 2 Early EBP has lower success rates than delayed procedures.

Contraindications and Precautions

• Follow neuraxial injection guidelines regarding antithrombotic therapy and low platelet counts. 2
• Exercise caution in febrile patients or those with systemic infection; defer EBP if hematogenous infection risk exists. 2
• Do NOT obtain routine blood cultures prior to EBP. 2

Alternative Procedural Options

Greater occipital nerve blocks may be offered for PDPH after spinal anesthesia with narrow-gauge needles (≈22G). 1, 2 However, headache recurrence is common, and a substantial proportion of patients ultimately require EBP. 1, 2 This represents a temporizing measure rather than definitive treatment.

Fluoroscopically guided transforaminal EBP may be used in patients with prior laminectomy near the puncture site or after unsuccessful interlaminar EBP. 2 This approach can succeed with smaller blood volumes (mean ≈7 mL). 2

Treatments to Avoid (Ineffective)

Do NOT use the following interventions, as they lack evidence of benefit: 1, 2

• Abdominal binders
• Aromatherapy
• Systemic hydrocortisone
• Theophylline
• Gabapentin
• Sphenopalatine ganglion blocks (insufficient evidence, grade I) 2

Red-Flag Features Requiring Urgent Neuroimaging BEFORE EBP

Obtain urgent brain imaging if any of the following are present: 1, 2

• Focal neurological deficits (visual disturbances, altered consciousness, seizures, cranial nerve palsies)
• Transition from orthostatic to non-orthostatic headache pattern
• New symptoms emerging after initial presentation
• Persistent or worsening symptoms despite prior EBP

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

Follow-Up and Long-Term Monitoring

Continue clinical follow-up until the headache has completely resolved. 1, 2 Premature discharge may miss serious complications.

Monitor for long-term sequelae including: 1, 2

• 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. 1

Communicate the PDPH diagnosis and management plan to the patient's primary care physician and relevant specialists. 1 This ensures continuity of care and appropriate long-term monitoring.