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 Headache

MRI 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.
    • In CUH, please contact (via switchboard) the consultant anaesthetist acting as theatre coordinator for the day (as per Dr Mary Walsh, March 2014).

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.



Conent by Dr Íomhar O' Sullivan 01/02/2010.Last review Dr ÍOS 27/08/14