Learning objectives

After reading this article you should be able to:

C recognize the diagnostic features of post-dural puncture

CORE: OBSTETRIC ANAESTHESIA

Post-dural punctureheadache in the parturientCathy Armstrong

headache (PDPH)

C summarize other causes of post-partum headache and recog-

nize worrying features requiring further investigation

C discuss the treatment options of PDPH

AbstractPost-dural puncture headache (PDPH) is one of the most common and

debilitating complications of neuraxial blockade in the parturient. The ob-

stetric population is at particular risk with up to 80% of women devel-

oping symptoms after inadvertent dural puncture during epidural

insertion. PDPH typically develops 24e48 hours post-puncture and is

classically described as an occipito-frontal headache with postural fea-

tures. Diagnosis and assessment should include consideration of other

potential causes of post-partum headache. At the time of inadvertent

dural puncture (IDP) one may insert an intrathecal catheter, re-site the

epidural or use alternative analgesia. Initial treatment of a PDPH includes

bed rest, adequate hydration and simple analgesics. Epidural blood patch

(EBP) remains the gold standard treatment of PDPH.

Keywords Accidental dural puncture; epidural blood patch; post-dural

puncture headache

Royal College of Anaesthetists CPD Matrix: 1A01, 1A02, 2B04, 2G04,

3B00

PDPH is a significant complication of central neuraxial blockade

(CNB). Cerebrospinal fluid (CSF) leakage into the epidural space

via a tear in the dura is thought to cause reduction in intra-cranial

pressure and a downward traction on pain-sensitive intra-cranial

structures, including meninges, veins and cranial nerves.

Compensatory vasodilatation due to CSF loss may also occur.1

Incidence

In the UK, the accepted rate of accidental dural puncture is less

than 1%.2 The obstetric population is at particular risk of

developing PDPH. Up to 80% of women with a recognized IDP

on insertion of an epidural develop symptoms. Spinal anaes-

thesia using narrow-gauge pencil-point needles (27G) have a

reduced PDPH incidence of less than 0.5%.

Symptoms

PDPH is classically described as an occipito-frontal headache

often radiating to the neck and shoulders with postural features

(exacerbated by sitting, standing, coughing and straining and

alleviated by lying flat). Typical presentation is 24e48 hours

post-puncture, although both immediate and later presentations

have been described. The International Classification of

Cathy Armstrong MBChB FRCA is a Consultant Obstetric Anaesthetist at

Central Manchester University Hospitals NHS Trust, Manchester, UK.

Conflicts of interest: none declared.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 14:8 320

Headache Disorders (ICHD) for PDPH is summarized in Table 1.

Associated features of PDPH include: nausea, vomiting, neck

stiffness, tinnitus and visual disturbances. Serious complications

such as cranial nerve palsy, convulsions or development of a

subdural haematoma can occur but are extremely rare.

Assessment and diagnosis

Symptoms of postural headache with a history of CNB are usually

sufficient to make a diagnosis of PDPH (up to 38% follow a

seemingly uneventful procedure). Potential differential diagnoses

range from benign self-limiting conditions to serious intra-cranial

pathologies requiring specialist intervention. When assessing a

patient with a potential PDPH it is important to consider other

causes (Table 2). A thorough assessment should be performed

including careful history and examination, with particular focus

on the timing and nature of the headache as well as other symp-

toms and signs. Worrisome features of post-partum headache that

should prompt further investigation include: focal neurological

symptoms, change in mental status, unilateral headache, head-

ache not relieved by pain medication, sudden uncontrollable

vomiting, co-existing medical issues (e.g. bleeding disorder,

immunocompromise) and PDPH not responding to epidural blood

patch, especially following two attempts.4

Prevention

Technique

Careful technique during insertion and avoidance of IDP is key.

While debate over safest loss of resistance technique continues, it

is likely that the least risk is presented when the operator uses

the technique most familiar to them. Operator inexperience, time

pressure, workload and fatigue are likely to increase IDP rate.

Needle choice

Narrow-gauge pencil-point needles (27G) have been shown to

reduce the incidence of PDPH following spinal anaesthesia to

0.37%.5 There is no definitive evidence advocating choice of a

particular epidural needle, 16G or 18G Tuohy needles continue to

be standard in the UK. A recent systematic review suggested that

use of combined spinal-epidural techniques did not pose a

significantly higher PDPH risk.6

Management at time of inadvertent dural puncture (IDP)

At the time of IDP the anaesthetist has three options:

� insert an intrathecal catheter;

� attempt to re-site another epidural in an alternative space;

� abandon regional analgesia and opt for an alternative

analgesic technique.

� 2013 Elsevier Ltd. All rights reserved.

International Classification of Headache Disordersdiagnostic criteria for post-dural puncture headache3

A Headache that worsens within 15 minutes after sitting or

standing and improves within 15 minutes after lying, with

at least one of the following and fulfilling criteria C and D:

C Neck stiffness

C Tinnitus

C Hyperacusia

C Photophobia

C Nausea

B Dural puncture has been performed

C Headache develops within 5 days after dural puncture

D Headache resolves spontaneously either:

C Spontaneously within 1 week

C Within 48 hours after effective treatment of cerebrospinal

fluid leak (usually by epidural blood patch)

Table 1

Potential advantages and disadvantages ofmanagement options following inadvertent duralpuncture (IDP)

Advantages Disadvantages

Intrathecal

catheter

insertion

C Good analgesia

C Extend block for

operative delivery

C Possible post-dural

puncture headache

reduction

C Avoid repeat dural

puncture

C Accidental misuse

C Risk of total spinal

C Unsafe if staff

unfamiliarity

C Possible increased

infection risk

Epidural

re-insertion

at another

level

C Good analgesia C Risk of repeat dural

puncture

C Risk of intrathecal

drug administration

through dural tear

Alternative

analgesia

C Avoidance of repeat

dural puncture in

labour

C Possible insufficient

analgesia

Table 3

CORE: OBSTETRIC ANAESTHESIA

Some evidence suggests that insertion of an intrathecal cath-

eter at the time of IDP is associated with a reduced incidence of

PDPH, although conflicting evidence exists. A Cochrane sys-

tematic review on this topic is currently in progress. Table 3 lists

the potential advantages and disadvantages of each option. UK

surveys have demonstrated an increase in the use of intrathecal

catheters following IDP over the past 10 years; safety concerns

remain the main reason for avoidance. All three options are

acceptable practice, the anaesthetist must make their manage-

ment decision based on the patient circumstances and local

policies/logistics but patient safety must always take precedent.

Any continuing regional technique following IDP will need

careful monitoring and management.

Other measures such as routine bed rest, intravenous fluids

and prophylactic epidural blood patch are not effective at pre-

venting PDPH.

Causes of post-partum headache

Primary

Migraine

Tension headache

Cluster

Vascular

Ischaemic stroke

Intra-cranial haemorrhage

Venous sinus thrombosis

Vasculitis

Migraine

Infection

Meningitis

Encephalitis

Pharmacological/metabolic

Dehydration

Drug use

Other

Post-dural puncture headache

Pre-eclampsia

Space-occupying lesion

Table 2

ANAESTHESIA AND INTENSIVE CARE MEDICINE 14:8 321

Treatment

Conservative measures

Once a PDPH has been diagnosed certain measures may help

symptomatic relief. These include bed rest (impractical for a

nursing mother), adequate hydration and simple analgesia.

Drugs

A recent systematic review on drug therapy for treating PDPH

had difficulty drawing conclusions due to lack of robust evi-

dence.7 There is some suggestion that caffeine may provide

symptomatic relief and possibly reduce the need for further in-

terventions. Gabapentin, theophylline and hydrocortisone may

reduce pain severity but are unlikely to negate the need for

further intervention. There was lack of conclusive evidence for

the use of sumatriptan or adrenocorticotropic hormone.

Epidural blood patch

Epidural blood patch (EBP) remains the gold standard treatment

of PDPH. The timing remains controversial but there is evidence

to suggest that the failure rate is increased if performed within

24e48 hours of symptoms. Beyond 24e48 hours an EBP should

be offered if symptoms persist, particularly if conservative

measures are ineffective and daily activities are restricted.

Procedure e injection of autologous blood into the epidural

space. Contraindications include sepsis, coagulopathy and patient

refusal. Two operators are required e one to find the epidural

space using a Tuohy needle, and the other to take blood from the

patient that can then be injected. Strict aseptic technique should be

adopted by both operators and the procedure should be performed

within a theatre environment. The optimal blood volume for in-

jection is unknown but general recommendations are 10e20ml. If

the patient reports pain during injection of blood then the proce-

dure should be stopped. It is no longer recommended to send off

routine blood cultures at the time of the procedure.

� 2013 Elsevier Ltd. All rights reserved.

CORE: OBSTETRIC ANAESTHESIA

Effectiveness e EBP successfully cures symptoms in approxi-

mately 45e65% of cases at the first attempt and 90e95% after

two attempts.8

Complications e minor complications include temporary

backache, neck pain and transient bradycardia. Repeat dural

puncture may occur. Other major complications are rare but

include meningitis, arachnoiditis and cauda equina syndrome.

Post-procedure e the patient should be observed for

1e2 hours, initially lying flat although bed rest beyond this is not

advocated. They should receive follow-up for a few days. Further

follow-up at 6 weeks is advisable. All patients should be

informed of how to access care if symptoms persist. A

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FURTHER READING

Thew M, Paech MJ. Management of postdural puncture headache in the

obstetric patient. Curr Opin Anaesthesiol 2008; 21: 288e92.

� 2013 Elsevier Ltd. All rights reserved.