- Normal volume of CSF ( adult) is 150 mL, ICP 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
- Incidence varies (2% with small bore needles, 40% post puncture with large bore)
- Usually immediately, may be delayed for weeks
- Usually frontal, burning, radiates to neck / shoulders
- Most resolve within 1 week:
- N.B. Headache minimal or absent supine alleviated by lying down or ↑CSF vol. (saline). MUST be present to make Dx
- Headache prominent in those with low substance P levels (lost during CSF leak)
- Risk factors include:
- 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
- Partially treated meningitis
- Intracranial abscess or empyema
- Venous sinus thrombosis
- Subdural haematoma
- 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)
- 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 (assumed to be a cerevral vasoconstrictor) - 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)
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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.