Post Lumbar Puncture Headache

Background

  • Normal volume of CSF ( adult) is 150 mL, intracranial pressure 5 - 15 mmHg
  • >400ml produced secreted and reabsorbed by the choroid plexus each day
  • Post LP headache is possibly due to intracranial hypotension post a CSF leak
    • Headache alleviated by lying down or increasing CSF volume (saline)
    • Headache prominent in those with low substance P levels (lost during CSF leak)

      Risk factors

        • 20-40 yo (x3 risk in older patients)
        • M: F = 2:1
        • Previous post LP headache or Hx chronic headaches
        • Low BMI
        • Larger needles, especially cutting type
        • Stylet not replaced during needle removal

        Features

        • Post LP headache incidence varies (2% with small bore needles, 40% post puncture with large bore)
        • Usually immediately, may be delayed for weeks

        NB - minimal or absent supine, triggered by sitting/standing (MUST be present to make Dx)

        • Usually frontal, burning, radiates to neck / shoulders
        • Most resolve within 1 week

Differential Dx

Please consider:

  • Partially treated meningitis
  • Intracranial abscess or empyema
  • Venous sinus thrombosis
  • Subdural haematoma

MRI Findings in Post LP HeadacheMRI findings

  • Crowding and caudal displacement (“sagging”) of the posterior fossa structures of the brain
  • Diffuse pachymeningeal enhancement
  • Engorgement of the epidural venous plexuses
  • Thoracic epidural collection (hence the high incidence of scapular "clothes hanger" pain reported).

 

 

 

 

Treatment

  • Please use smaller bore, traumatic (blunt) needles and replace stylet [BestBets] prior to removal
  • Bed rest has no influence in risk of post LP headache. But . symptoms resolve lying down.
  • Hydration post LP - no evidence either way, though pre-LP headache reported in dehydrated patients
  • Sumatriptan - no convincing evidence for or against
  • Caffeine - evidence inconclusive - worth a try
  • Epidural blood patch [Cochrane]
    • (20ml patient's own blood) - indicated for more severe / debilitating symptoms.
    • Best used early post symptom onset.

Further reading

Chiapparini L, Ciceri E, Nappini S, Castellani MR, Mea E, Bussone G, et al. Headache and intra-cranial hypotension: neuroradiological findings. Neurol Sci2004;25(suppl 3):S138-41.

Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA2006;295:2286-96.

Chung SJ, Kim JS, Lee MC. Syndrome of cerebral spinal fluid hypovolemia: clinical and imaging features and outcome. Neurology2000;55:1321

Ahmed SV, Jayawarna C, Jude E. Post lumbar puncture headache: diagnosis and management. Postgrad Med J2006;82:713-6.

Raymond JR, Raymond PA. Post-lumbar puncture headache: etiology and management. West J Med1998;148:551-4.

Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth2003;91:718-29.

Sudlow C, Warlow C. Epidural blood patching for preventing and treating postdural puncture headache. Cochrane Database Syst Rev2010;1:CD001791.