19. Post-Dural Puncture Headache

Question 1

Describe the common causes
and presentation of a post-dural
puncture headache (PDPH).

Answer 1

Dural puncture is intentional in
subarachnoid anaesthesia and a recognised
complication of epidural placement.

Puncturing the dura can result in
leakage of CSF from the tear,

a fall in ICP and

sagging of the brain in the
skull vault,

which can lead to the development of a debilitating postural headache.

The headache usually occurs 
within 72 hours of dural puncture,
 is classically severe, 
frontal/occipital/retrobulbar and
 may radiate into the
neck and shoulders. 

The pain is worse on sitting or standing and improved
by lying down.

There may be associated 
nausea and vomiting,
photophobia,
 tinnitus,
hearing loss, 
vertigo, 
paraesthesia of the scalp or upper and lower
limbs. 

In every instance, other causes of headache must be considered and excluded.

Question 2

What is the incidence of PDPH?

Answer 2

The incidence of accidental dural puncture during epidural anaesthesia is 0–2.6%
and is inversely proportional
to the experience of the anaesthetist.

Incidence of post-dural puncture headache (PDPH) following spinal depends on the type and gauge of needle used:

with 25 g Whitacre incidence is
0–14.5%,

24 g Sprotte 0–9.6%.

The most common place you will encounter dural punctures and PDPH is in the maternity unit because of the large numbers of epidurals sited in labouring women.

Question 3

You are inserting an epidural into
a woman in early labour. You
suspect you may have
accidentally punctured the dura.
Describe your management.

Answer 3

Management of an accidental
dural puncture can be classified as
immediate,
early and late:

Immediate management:

> Confirm dural puncture:

this may be extremely obvious
if there is CSF leaking briskly from the Tuohy needle!

Otherwise CSF can be identified
by feeling the temperature
of the fluid on your un-gloved hand
or dip the fluid with a urine dipstix:

• CSF warm,
pH 7.5–8.5,
trace/+ glucose,
+/++ protein

• Saline cool, pH 5–7.5, no glucose, no protein.

> Once dural puncture is confirmed,
there are two management options available:

• Remove the needle/catheter and re-site the epidural at a different interspace.

Run the epidural as needed following this, but beware of intrathecal spread of local anaesthetic.
Only an anaesthetist should give top ups.

Question 4

Analgesia

Answer 4

> T he woman should be given regular simple analgesia and opioids if
needed (NB: do not give codeine to breastfeeding women).
C affeine, sumatriptan, abdominal binders: none of these traditional
treatments has been shown to be effective.

Question 5

Early Management:

Late management of PDPH:

Answer 5

Early Management:
Arrange daily follow-up for the woman by an anaesthetist and give her
written information, e.g. OAA leaflet.

Conservative treatment

> Bed rest. Most PDPHs resume spontaneously after around 10 days.

Traditional teaching encouraged fluid administration, but this has not been shown to be of benefit,
although it is advisable to avoid dehydration.

> Avoid raising ICP:

prescribe laxatives to all with PDPH to avoid the need
to strain at stool.

Advise patients to avoid lifting heavy loads or other
activities that will cause straining.

Question 6

Analgesia

Answer 6

> The woman should be given regular
simple analgesia and opioids if needed
(NB: do not give codeine to breastfeeding women).

> Caffeine, sumatriptan, abdominal binders: none of these traditional treatments has been shown to be effective.