What oral caffeine dose is recommended for treating a post‑dural puncture (spinal) headache in an adult without contraindications such as uncontrolled hypertension, cardiac arrhythmia, pregnancy, or severe anxiety?

Oral Caffeine Dose for Post-Dural Puncture Headache

Administer oral caffeine up to 900 mg per day (or 200–300 mg per day if breastfeeding) within the first 24 hours of symptom onset for treating post-dural puncture headache. 1

Dosing Recommendations

• The maximum recommended dose is 900 mg per day, administered within the first 24 hours of headache onset (evidence grade B). 1, 2
• For breastfeeding patients, reduce the dose to 200–300 mg per day to minimize infant exposure. 1, 2
• Caffeine provides temporary symptomatic relief but is not a definitive treatment for persistent or severe PDPH. 3

Clinical Context and Timing

• Caffeine is most effective when used early—within the first 24 hours of symptom onset—as part of initial conservative management. 1, 2
• The American Society of Regional Anesthesia and Pain Medicine recommends caffeine as a first-line conservative measure alongside multimodal analgesia (acetaminophen and NSAIDs) and adequate hydration. 1
• Caffeine reduces the proportion of patients with persistent PDPH and decreases the need for supplementary interventions when compared to placebo. 4

Mechanism and Expected Benefit

• Caffeine acts as a cerebral vasoconstrictor, counteracting the venous dilatation and meningeal traction caused by CSF leak and intracranial hypotension. 3
• One RCT demonstrated that caffeine reduced the number of participants with PDPH at one to two hours post-administration and decreased the need for additional therapeutic options. 4
• A 2024 trial showed that prophylactic acetaminophen plus caffeine (65 mg every 6 hours) reduced PDPH risk by 70% and attenuated pain intensity at 18,48, and 72 hours post-spinal anesthesia. 5

Important Caveats and Limitations

• Caffeine provides only temporary relief; headache may recur after the effect wears off. 6, 4
• The United Kingdom Joint Specialist Societies explicitly classify caffeine as a "NOT proven practice" for preventing PDPH, noting no evidence that oral or intravenous caffeine prevents headache after lumbar puncture. 3
• Excessive caffeine administration can cause adverse effects including withdrawal syndrome, dehydration, and even seizures. 3
• Avoid combining multiple caffeine sources (e.g., coffee, tea, energy drinks, medications) to prevent inadvertent overdose and adverse effects. 2

When Caffeine Is Insufficient

• If symptoms are severe or do not begin to resolve after 2–3 days, proceed to epidural blood patch (EBP), which remains the definitive treatment with success rates exceeding 90%. 1
• Short-term opioids may be considered if multimodal analgesia (acetaminophen, NSAIDs, and caffeine) fails to control pain, but avoid long-term opioid use. 1, 2
• Greater occipital nerve blocks may be offered for PDPH after narrow-gauge spinal needles, though headache recurrence is common and many patients ultimately require EBP. 1, 2

Practical Administration

• Oral caffeine can be administered as caffeine tablets, caffeine sodium benzoate, or strong coffee (approximately 100–150 mg caffeine per 8 oz cup). 6
• Divide the total daily dose (up to 900 mg) into multiple administrations throughout the day to maintain therapeutic levels and minimize side effects. 2
• Ensure adequate hydration (oral or intravenous if oral intake is insufficient) to support overall management. 1, 2