REVIEW ARTICLE

Review article

Post- 818 – 21

Karl Bjørnar Alstadhaug Definition Summary [email protected] According to the International Classification Department of Headache Disorders (ICHD-II), post-dural Background. Headache is a complica- Nordland Hospital Bodø puncture headache is iatrogenically conditio- tion of lumbar puncture that has been and Institute of Clinical Medicine ned caused by low pres- known for well over a century. The aim University of Tromsø sure in the spinal fluid space. Diagnostic cri- of this paper is to provide an overview Francis Odeh teria are listed in Box 1 (3). It is worth noting of the incidence and symptoms of, the Farid Khan Baloch that these can occur considerably risk factors for and the treatment of Diana Hristova Berg later than five days after a lumbar puncture, this type of headache. Neurology Department and that at worst the condition may last for Nordland Hospital Bodø months and even years (4). Method. The article is based on a Rolf Salvesen search in PubMed for studies on head- Neurology Department Incidence ache after lumbar puncture followed Nordland Hospital Bodø The risk of developing a headache as a result by a discretionary selection of publica- and Institute of Clinical Medicine of a lumbar puncture depends on a number tions. University of Tromsø of factors, and the incidence will therefore Results. Post-dural puncture headache vary widely, depending on the populations (PDPH) is characterised by the occur- studied and the needles and techniques that rence of a headache with a definite have been used (5, 6). The diameter, or gauge orthostatic component within five days (gg), of the lumbar puncture needle (7), and of a lumbar puncture. The incidence the shape of the point (Fig. 1) appear to be the most important individual factors with a depends on a number of factors. Youn- Lumbar puncture, also known as spinal puncture, involves passing a needle through bearing on the incidence (5, 6, 8 – 12). ger women with a previous history of the wall of the dural sac (Fig. 1) (1) and into In a review of literature from 1966 to 2000, headaches appear to be at highest risk. the subarachnoid space, which is filled with Evans et al. found that when needles of gauge The incidence can be significantly redu- , in the lumbar portion of 20 – 22 gg were used (typical of diagnostic ced by using a thin lumbar puncture the back. This is normally done in connec- spinal puncture) the incidence was 20 – 40 % needle with an atraumatic tip. The con- tion with diagnostics – to measure the pres- (5). Post-dural puncture headache occurs dition is self-limiting and harmless, but sure in the subarachnoid space, to analyse roughly twice as often with diagnostic lum- leads to significant morbidity. cerebrospinal fluid, to inject contrast me- bar puncture as with spinal anaesthesia. The alleviates the symptoms and reduces dium for or in connection with main reason is almost certainly that a thin the course of the illness. When bed rest spinal anaesthesia. Lumbar puncture may needle, often with an atraumatic point (11), is and caffeine prove ineffective, an epidu- occasionally have a therapeutic purpose, for usually used in spinal anaesthesia. ral blood patch works well for the majo- example in cases of idiopathic intracranial In 2001, Strupp et al. showed that over rity, but there is no consensus as to hypertension. The dural sac may also have a 12 % of 115 patients who were subjected to when such treatment should be offered. hole after epidural anaesthesia/analgesia. diagnostic lumbar puncture with a 22 gg (0.7 Lumbar puncture may cause post-dural Interpretation. Headaches frequently puncture headache (PDPH). The «father of occur after lumbar punctures. There is spinal anaesthesia», August Bier (1861 – substantial evidence for recommending 1949), is believed to have reported the first the use of a thin, atraumatic needle cases well over 100 years ago (2). The pur- Main points to reduce the incidence. For practical pose of this article is to provide an updated ■ Post-dural puncture headache is an reasons, a needle thinner than 22 status for the condition. important cause of iatrogenic morbidity gauge (gg) is not suitable for diagnostic following a lumbar puncture lumbar punctures. Method ■ The risk of inflicting a post-dural punc- The article is based on a discretionary selec- ture headache on the patient is sub- tion of articles that we found by searching in stantially reduced by using a needle PubMed on the following search phrases: with a small diameter and an atrauma- «headache after lumbar puncture», «post- tic point dural puncture headache», «post-lumbar ■ The majority of patients with post-dural puncture headache», «post-puncture head- puncture headache are free of pain ache», «post-spinal headache», «epidural within a few days with conservative blood patch». The search was concluded on treatment 31 August 2011. Only English-language and ■ An epidural blood patch may be con- Scandinavian literature were considered. sidered after only 1 – 2 days if the head- Weight was attached to the results of ran- ache is severe and incapacitating domised controlled studies, consensus docu- ments and systematic overviews.

818 Tidsskr Nor Legeforen nr. 7, 2012; 132: 818 – 21 REVIEW ARTICLE

mm) atraumatic needle suffered post-dural puncture headache, while over 24 % of 115 who were given a lumbar puncture with a 22 gg traumatic needle suffered a headache (1). This finding provided the basis for an Amer- ican recommendation to use a 22 gg atrau- matic needle for diagnostic lumbar puncture (9). A later study with 58 patients has shown an even greater difference (36 % versus 3 % post-dural puncture headache) when an atraumatic needle is used (10). International practice (11, 12) and practice at most neurological departments in Norway is not in line with these findings or with the American recommendation. An informal inquiry to all eighteen heads of neurology departments in Norway in 2011 showed that Figure 1 Hole in dural sac caused by pencil point needle (conical, atraumatic needle) and Quincke ground only three departments routinely used an needle (cutting). Reproduced with permission from Neurology (1) atraumatic needle for diagnostic lumbar puncture (unpublished data). Post-dural headache may also occur in Risk factors this reason the use of atraumatic needles connection with unintentional dural perfor- The risk factors for headache after spinal tends to be regarded as technically more chal- ation, for example in unsuccessful attempts puncture can be classified as non-modifiable lenging. This may be one reason why trau- to insert an epidural catheter in obstetric or modifiable (Table 1) (6, 25). The inci- matic needles are still used to a large extent in patients, but this is relatively rare (in about dence is relatively low in children (26) and neurological circles. However, studies indi- 1 %) (7). It is nonetheless worth noting that inversely proportional to age in adults, with cate that a cutting needle may be the most the majority of birthing mothers suffering a the highest incidence in the age group difficult to use (30). perforated dura develop post-dural puncture 20 – 40. Post-dural puncture headache sel- A higher number of punctures, due to inex- headache. dom occurs in persons aged over 60 (5, 6, perience on the part of those performing the 27). Women are twice as much at risk as men lumbar puncture, may increase the incidence Pathophysiology (5, 6, 27). Persons with or other of post-dural puncture headache somewhat As a result of buoyancy in the cerebrospinal chronic headache, and those who have pre- (32), but as a rule these technical difficulties fluid, the weight of the structures in the cen- viously had post-dural puncture headache, are of minor importance. Nor do the patients’ tral is reduced to around 50 g have about three times as high a risk of posture, degree of hydration, puncture level, (13). The pressures and tensions on the cen- developing the condition (5, 22). In a study opening pressure, quantity of cerebrospinal tral nervous structures are accordingly redu- with 501 patients, Kuntz et al. (28) found fluid drawn or their remaining lying in bed ced to a minimum. When the patient is in a that a low body mass index (BMI) was a risk after the lumbar puncture appear to have a vertical position, the pressure in the cerebro- factor for headache after spinal puncture. major bearing on the development of post- spinal fluid is negative, at around –10 mm Hg The difference in average body mass was dural puncture headache (5, 33). (14), but this increases markedly when the very modest, however (24.3 kg/m2 versus In a meta-analysis of 2006, Richman et al. patient is in a horizontal position, usually to 25.8 kg/m2), and the clinical relevance of around 7 – 15 mm Hg (15). An older explana- this finding is uncertain. tory model (16) for headache caused by spinal As previously mentioned, the most im- Box 1 puncture is that the pressure is too low as a portant modifiable risk factor is the needle result of persistent spinal fluid leakage used in the procedure. The calibre of the Post-dural puncture headache through the hole in the dura, causing traction needle is directly associated with the inci- (according to ICHD-II) on pain-sensitive structures (meningeal mem- dence of post-dural puncture headache (5, branes, blood vessels and nerves) (17 – 19). 29, 30). The larger the needle, the larger the ■ The headache occurs within five days The underlying mechanisms are undoubt- perforation in the dura, and the higher the of a lumbar puncture edly more complex (20 – 25). According to risk of a persistent . ■ The headache intensifies within 15 the Monro-Kellie-Burrows doctrine (the sum However, needles that are too thin cannot be minutes of the patient sitting or stan- of the volumes of the cerebrospinal fluid, the used, for practical reasons. If, for example, a ding up from a recumbent position, and blood and the tissue in the remain needle of < 22 gg were to be used for dia- abates within 15 minutes of the patient constant), loss of cerebrospinal fluid may gnostic lumbar puncture, collecting cerebro- lying down result in compensatory intracranial vasodila- spinal fluid would take an unreasonably ■ The headache is accompanied by at tion. Relative cerebrospinal fluid hypovola- long time. The American Academy of least one of the following: emia (23) which results in painful, possibly Neurology (AAN) therefore recommends – Stiff neck adenosine-receptor-mediated (24), vasodila- that 22 gg be the thinnest needle used for – tion is thus another main hypothesis. In a diagnostic lumbar puncture (9). – Hyperacusis clinical trial, Clark et al. found that a low As previously mentioned, using an atrau- – level of substance P, a neuropeptide associ- matic needle can also substantially reduce the – ated with neurogenic , resulted incidence of post-dural puncture headache (1, in a three times higher risk of developing 5, 10, 31). A non-cutting needle makes a ■ The headache disappears spontane- headache after spinal puncture (25). As a smaller puncture hole in the dura than a cut- ously within a week or within 48 hours result, it was postulated that those who were ting one, because the dural fibres are pushed after the cerebrospinal fluid leak has predisposed were hypersensitive to substance aside instead of being cut. With an atraumatic been effectively treated (normally with P as a result of premorbid upregulation of its needle, an «introducer needle» is usually an epidural blood patch) receptor (neurokinin-1 receptor). used initially to penetrate the skin, and for

Tidsskr Nor Legeforen nr. 7, 2012; 132 819 REVIEW ARTICLE

extracting 10 – 30 ml of blood (6) from one Table 1 Risk factors for developing post-dural puncture headache. Modified after Bezov et al. (6) of the patient’s veins and injecting it slowly into the . After the procedure, Non-modifiable Modifiable the patient should remain lying down for Age Size and type of needle 1 – 2 hours. Over 75 % of patients will be Gender female Technical construction cured of their headache after this. If the Low body mass index? Angle of needle and the cutting surface attempt fails, a better result can often be Known headache problems or previous of the needle on puncturing obtained by repeating it (7, 35, 42). Some of post-dural puncture headache Replacement of mandrin in the needle Low concentration of substance P in cerebro- Experience (of epidural/spinal anaesthesia) the effect may be due to spontaneous remis- spinal fluid (25) sion, since the result is poor if the treatment is administered prophylactically (42) or within 24 hours of the lumbar puncture (43). showed that the angling of the needle during haemorrhaging, and preeclampsia CT-guided injection of can be penetration, cranially rather than perpendi- are important differential diagnoses (5, 37). effective if application of an epidural blood cular to the long axis of the spine, may sig- In cases of low-pressure headache, inclu- patch fails (44). Surgical closure of the leak, nificantly reduce the incidence of post-dural ding post-dural puncture headache, MRI of which in the event must be located radio- puncture headache (34). Replacing the the head tends to show diffuse pachymenin- logically, may occasionally be a last resort mandrin in the needle before the needle is geal enhancement due to the contrast me- (45). Complications rarely occur with epidu- removed has also proved to be beneficial, dium (Fig. 2) and reduced ventricle size; the ral blood patches, but adhesive arachnoidi- particularly when atraumatic needles are cerebellar tonsils may extend down into the tis, subdural haematoma and bacterial me- used (5). and basal cisterns may be ningitis have been reported (46). There is no flattened or eliminated, or the hypophysis consensus as to when an epidural blood Clinical characteristics may be enlarged (11). In the event of doubt, patch should be offered, but it does not seem and diagnostics CT myelography, cisternography or spinal unreasonable to offer it to patients with very Nine out of ten patients with post-dural punc- MR with thin sections may reveal where the severe headache after 24 – 48 hours. ture headache develop symptoms within 72 cerebrospinal fluid leak is located (38). hours of a lumbar puncture (3, 27). The head- Conclusion ache occurs or is exacerbated when the pa- Treatment and prognosis Spinal puncture is an important cause of tient is upright, and abates or goes away when Post-dural puncture headache has in prin- iatrogenic morbidity in the form of post-dural the patient is lying down. The exacerbation ciple a self-limiting course. Given a conser- puncture headache. The incidence of these after the patient stands up normally occurs vative approach in the form of rest, good headaches can be reduced by using thin atrau- within 20 seconds, as does the relief when the hydration and treatment of symptoms, over matic needles in the procedure, however. patient lies down (15). The location, quality 50 % of patients recover within four days, and intensity of the pain are of little dia- just over 70 % within a week and over 85 % gnostic value. within six weeks (27, 39). Caffeine is first- Karl Bjørnar Alstadhaug (born 1972) The headache may incapacitate patients line treatment, and a recently published Specialist in neurology, Senior Consultant and (35), and quite often leads to hospitalisation Cochrane report documents symptom relief Associate Professor. (36). Pulsating pain accompanied by nausea and a shorter course of illness where caffe- The author has completed the ICMJE form and and hypersensitivity to light and sound can ine is used (40). Gabapentin, theophylline reports no conflicts of interest. make it difficult to distinguish the condition and hydrocortisone can also alleviate the from a migraine attack. As indicated by the headache, but not shorten the course of the Francis Odeh (born 1971) diagnostic criteria (Box 1), loss of hearing illness (40). PhD, Junior Registrar with the Neurology and tinnitus are not unusual. When the head- Blood proves to coagulate on contact with Department, Nordland Hospital Bodø. ache is not postural, accompanied by cranial cerebrospinal fluid (41), and the reason for The author has completed the ICMJE form and nerve effects, stiff neck, fever or visual im- applying an epidural blood patch is that the reports no conflicts of interest. pairment, it is important to exclude other blood will seal the dural hole created by the conditions. Intracranial venous thrombosis, puncture needle. The procedure consists of Farid Khan Baloch (born 1979) Doctor in specialist training with the Neurology Department, Nordland Hospital Bodø. The author has completed the ICMJE form and reports no conflicts of interest.

Diana Hristova Berg (born 1975) Doctor in specialist training with the Neurology Department, Nordland Hospital Bodø. The author has completed the ICMJE form and reports no conflicts of interest.

Rolf Salvesen (born 1952) Head of the Neurology Department, Nordland Hospital Bodø, and Adjunct Professor at the University of Tromsø. He has published articles on migraine and nationally and internationally. The author has completed the ICMJE form and reports no conflicts of interest.

Figure 2 Cerebral MRI – a) from the side, b) from below – shows pachymeningeal enhancement with gado- linium in a man with postural headache and lumbar spinal fluid leakage. © Nordland Hospital Bodø >>>

820 Tidsskr Nor Legeforen nr. 7, 2012; 132 REVIEW ARTICLE

References needles during a lumbar puncture. J Neurol Neu- 33. Sudlow C, Warlow C. Posture and fluids for pre- 1. Strupp M, Schueler O, Straube A et al. «Atrauma- rosurg Psychiatry 2004; 75: 893 – 7. venting post-dural puncture headache. Cochrane tic» Sprotte needle reduces the incidence of post- 18. Hatfalvi BI. Postulated mechanisms for postdural Database Syst Rev 2002; nr. 2: CD001790. lumbar puncture headaches. Neurology 2001; 57: puncture headache and review of laboratory 34. Richman JM, Joe EM, Cohen SR et al. Bevel direc- 2310 – 2. models. Clinical experience. Reg Anesth 1995; 20: tion and postdural puncture headache: a meta- 2. Bier A. Versüche uber Cocainiserung des Rücken- 329 – 36. analysis. Neurologist 2006; 12: 224 – 8. markes. Dtsch Z Chir 1899; 51: 361 – 9. 19. Kunkle EC, Ray BS, Wolf HG. Experimental studies 35. van Kooten F, Oedit R, Bakker SL et al. Epidural 3. Headache Classificaion Subcommittee of the on headache: Analysis of headache associated blood patch in post dural puncture headache: International Headache Society. The International with changes in . Arch Neurol a randomised, observer-blind, controlled clinical Classification of Headache Disorders: 2nd edition. Psychiatry 1943; 49: 323 – 58. trial. J Neurol Neurosurg Psychiatry 2008; 79: Cephalalgia 2004; 24 (suppl 1): 79. 20. Mokri B, Atkinson JL, Piepgras DG. Absent head- 553 – 8. 4. Baerentzen FO, Mathiesen O. Postdural hovedpine ache despite CSF volume depletion (intracranial 36. Tohmo H, Vuorinen E, Muuronen A. Prolonged gennem fire år. Ugeskr Læger 2007; 169: 3873 – 4. hypotension). Neurology 2000; 55: 1722 – 4. impairment in activities of daily living due to post- 5. Evans RW, Armon C, Frohman EM et al. Assess- 21. Levine DN, Rapalino O. The pathophysiology of dural puncture headache after diagnostic lumbar ment: prevention of post-lumbar puncture hea- lumbar puncture headache. J Neurol Sci 2001; puncture. Anaesthesia 1998; 53: 299 – 302. daches: report of the therapeutics and technology 192: 1 – 8. 37. Kanazi G, Abdallah F, Dabbous A et al. Headache assessment subcommittee of the american aca- 22. Amorim JA, Valença MM. Postdural puncture and nuchal rigidity and photophobia after an epi- demy of neurology. Neurology 2000; 55: 909 – 14. headache is a risk factor for new postdural punc- dural blood patch: diagnosis by exclusion of per- 6. Bezov D, Lipton RB, Ashina S. Post-dural puncture ture headache. Cephalalgia 2008; 28: 5 – 8. sistent post-dural puncture headache mimicking headache: part I diagnosis, epidemiology, etiology, 23. Miyazawa K, Shiga Y, Hasegawa T et al. CSF meningitis. Br J Anaesth 2010; 105: 871 – 3. and pathophysiology. Headache 2010; 50: 1144 – 52. hypovolemia vs intracranial hypotension in «spon- 38. Spelle L, Boulin A, Pierot L et al. Spontaneous 7. Paech MJ, Doherty DA, Christmas T et al. The taneous intracranial hypotension syndrome». intracranial hypotension: MRI and radionuclide volume of blood for epidural blood patch in obstet- Neurology 2003; 60: 941 – 7. cisternography findings. J Neurol Neurosurg rics: a randomized, blinded clinical trial. Anesth 24. Camann WR, Murray RS, Mushlin PS et al. Effects Psychiatry 1997; 62: 291 – 2. Analg 2011; 113: 126 – 33. of oral caffeine on postdural puncture headache. 39. Jones RJ. The role of recumbency in the preven- 8. Pöll JS. The story of the gauge. Anaesthesia 1999; A double-blind, placebo-controlled trial. Anesth tion and treatment of postspinal headache. Anesth 54: 575 – 81. Analg 1990; 70: 181 – 4. Analg 1974; 53: 788 – 96. 9. Armon C, Evans RW. Addendum to assessment: 25. Clark JW, Solomon GD, Senanayake PD et al. Sub- 40. Basurto Ona X, Martínez García L, Solà I et al. Drug Prevention of post-lumbar puncture headaches: stance P concentration and history of headache therapy for treating post-dural puncture hea- report of the Therapeutics and Technology in relation to postlumbar puncture headache: dache. Cochrane Database Syst Rev 2011; nr. 8: Assessment Subcommittee of the American towards prevention. J Neurol Neurosurg Psych- CD007887. Academy of Neurology. Neurology 2005; 65: iatry 1996; 60: 681 – 3. 41. Cook MA, Watkins-Pitchford JM. Epidural blood 510 – 2. 26. Janssens E, Aerssens P, Alliët P et al. Post-dural patch: a rapid coagulation response. Anesth Analg 10. Lavi R, Yarnitsky D, Rowe JM et al. Standard vs puncture headaches in children. A literature 1990; 70: 567 – 8. atraumatic Whitacre needle for diagnostic lumbar review. Eur J Pediatr 2003; 162: 117 – 21. 42. Boonmak P, Boonmak S. Epidural blood patching puncture: a randomized trial. Neurology 2006; 67: 27. Dripps RD, Vandam LD. Long-term follow-up of for preventing and treating post-dural puncture 1492 – 4. patients who received 10,098 spinal anesthetics: headache. Cochrane Database Syst Rev 2010; 11. Lavi R, Rowe JM, Avivi I. Lumbar puncture: it is failure to discover major neurological sequelae. nr. 1: CD001791. time to change the needle. Eur Neurol 2010; 64: J Am Med Assoc 1954; 156: 1486 – 91. 43. Berrettini WH, Simmons-Alling S, Nurnberger JI 108 – 13. 28. Kuntz KM, Kokmen E, Stevens JC et al. Post- jr. Epidural blood patch does not prevent headache 12. Arendt K, Demaerschalk BM, Wingerchuk DM et lumbar puncture headaches: experience in 501 after lumbar puncture. Lancet 1987; 1: 856 – 7. al. Atraumatic lumbar puncture needles: after all consecutive procedures. Neurology 1992; 42: 44. Gladstone JP, Nelson K, Patel N et al. Spontan- these years, are we still missing the point? Neuro- 1884 – 7. eous CSF leak treated with percutaneous CT- logist 2009; 15: 17 – 20. 29. Rasmussen BS, Blom L, Hansen P et al. Postspi- guided fibrin glue. Neurology 2005; 64: 1818 – 9. 13. Dahl HA, Olsen BR, Rinvik E. Menneskets anatomi. nal headache in young and elderly patients. 45. Schievink WI, Morreale VM, Atkinson JLD et al. Oslo: Cappelen, 1993. Two randomised, double-blind studies that com- Surgical treatment of spontaneous spinal cerebro- 14. Albeck MJ, Børgesen SE, Gjerris F et al. Intracra- pare 20- and 25-gauge needles. Anaesthesia 1989; spinal fluid leaks. J Neurosurg 1998; 88: 243 – 6. nial pressure and cerebrospinal fluid outflow con- 44: 571 – 3. 46. Banks S, Paech M, Gurrin L. An audit of epidural ductance in healthy subjects. J Neurosurg 1991; 30. Halpern S, Preston R. Postdural puncture hea- blood patch after accidental dural puncture with 74: 597 – 600. dache and spinal needle design. Metaanalyses. a Tuohy needle in obstetric patients. Int J Obstet 15. Chapman PH, Cosman ER, Arnold MA. The rela- Anesthesiology 1994; 81: 1376 – 83. Anesth 2001; 10: 172 – 6. tionship between ventricular fluid pressure and 31. Hammond ER, Wang Z, Bhulani N et al. Needle body position in normal subjects and subjects with type and the risk of post-lumbar puncture hea- shunts: a telemetric study. Neurosurgery 1990; 26: dache in the outpatient neurology clinic. J Neurol 181 – 9. Sci 2011; 306: 24 – 8. 16. MacRobert RG. The cause of lumbar puncture 32. Seeberger MD, Kaufmann M, Staender S et al. Received 23 August 2011, first revision submitted headache. JAMA 1918; 70: 1350 – 3. Repeated dural punctures increase the incidence 17. Reina MA, López A, Badorrey V et al. Dura-arach- of postdural puncture headache. Anesth Analg 1 October 2011, approved 9 February 2012. Medical noid lesions produced by 22 gauge Quincke spinal 1996; 82: 302 – 5. editor: Trine B. Haugen.

Tidsskr Nor Legeforen nr. 7, 2012; 132 821