Post dural puncture headache
Sources
uptodate.com
Obstetric Anaesthetists Association
Individual hospital guidelines and protocols
GUIDELINES AND CARE PATHWAYS
Diagnosis
What are other hospitals doing?
Need for updated protocol in LUH
"A headache occurring after dural puncture that has a significant effect on the patient's post operative well being (ie) a headache which is not only postural but also continues for more than 24 hours at any level of intensity or so severe at any time that the patient is unable to maintain an upright position"
Epidemiology and prognosis
NHS - Royal Berkshire
- Occipito-frontal
- Often associated with neck pain
- Immediately (rare) - 72 hrs post puncture
- Relieved by lying flat
- Associated: photophobia, tinnitus, vertigo, nausea, vomiting, hearing loss, parasthesia of the scalp. Dipolpia and cortical blindness have been described
- Extreme - grand mal seizures
- Severe and incapacitating - psychological impact
- Other causes MUST be outruled if NO postural features
- Incidence:
- 10-30% following lumbar puncture
- Timing
- 90% occur within 3 days
- 66% within 24 hrs
- Can occur up to 14 days post procedure
- Prognosis:
- 72% resolve spontaneously within 7 days
- Can persist months - years
Post partum headache
- common, 40%
- Common headache
- Tension headache
- Migraine
- Infection - Meningitis
- Intracranial tumours
- Intracranial haematomas
- Pituitary apoplexy
Investigations
When in doubt...
- LP + manometry: decreased CSF pressure
- MRI
- Myelography or thin-section MRI can be used to located to the source of the CSF leak
Treatment conservative
Analgesia regimen
Paracetamol 1 g qds
Ibuprofen 400 mg qds
Codeine30-60 mg qds prn
- Daily review by an anaesthetist
- Talk, explain, reassure
- Regular analgesia
- Caffeine
- Stool softeners
Treatment Other
Epidural Blood Patch
- Most effective 24-48 hr post puncture
- 70-80% get some or complete relief
Migraine drug
Has been of benefit in some women
- Epidural blood patch
- Sumatriptan
- Abdominal binders
Obtained through physiotherapy