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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

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