Post Lumbar Puncture Headache

Post LP Headache

 

Performing a lumbar puncture in the ED is certainly a task with which we are very familiar.  We have discussed potential reasons to perform a lumbar puncture (ex, HeadachesPseudotumor cerebri, and Mollaret’s Meningitis). We have also covered strategies to make your first attempt you best attempt as well as what to do when the tap is traumatic. Now let us consider the potential for complication from your lumbar puncture: Post Lumbar Puncture Headache.

 

Post Lumbar Puncture Headache

  • Post Lumbar Puncture (AKA, Post Dural Puncture) Headache is one of the most common complications of the LP.
  • Several proposed mechanisms exist, but often thought to be due to continued CSF leakage through a dural tear
  • Studies including adult patients have shown incidences of around 1/4th of cases,but also as high as 1/3rd of patients. [Khlebtovsky, 2015; Monserrate, 2015]
  • Incidence in pediatrics is similar – 25% [Leblanc, 2005]
  • Diagnostic Criteria

    1. Headache that increases w/in 15 min of standing, improves w/in 15 min of lying down, and has ONE of the following AND also fulfills the remaining criteria:
        • Neck stiffness
        • Tinnitus
        • Hyperacusis
        • Photophobia
        • Nausea
    2. Dural puncture has been performed
    3. Headache develops within 5 days of dural puncture
    4. Headache resolves either, spontaneously w/in 1 week or within 48 hours after effective treatment (usually, epidural blood patch).

[International Classification of Headache Disorders, 3rd Edition, 2013]

 

Help Avoid the Post LP Headache

  • Post lumbar Puncture Headache is often an avoidable iatrogenic complication. [Davis, 2014]
  • Patient “anxiety” does not predispose to the occurrence of post LP headache. [Khlebtovsky, 2015]
  • Bed-rest/remaining supine has not been shown to decrease post LP headache. [Jacobus, 2012]
  • Reinsert stylet prior to needle withdrawal 
  • Direct bevel perpendicular to the dura
  • Use smaller needle size  
  • Use an Atraumatic Needle

    • So this may not be up to you entirely, as it depends on what tools you have available, but…
    • It has been shown that needle type influences rates of Post LP Headache [Bertolotto, 2015; Davis, 2014]
    • “Cutting” needles (ex,Quincke) are most commonly used, but lead to greater risk of Post LP headache. 
    • Atraumatic (ex, Whitacre, Sprotte) have lower rates of Post LP Headache [Bertolotto, 2015]
    • Examples
      • Neelde
    • Atraumatic needles spread out the fibers of the dura, causing less trauma. 
    • Atraumatic needles require “more skill” as they cannot cut through skin, muscle, etc and need an introducer to do that job. 
    • See SpinalCSFLeak.org

 

Treat the Post LP Headache

  • Conservative management is usually first option, because resolution often occurs within first week. 
  • Intravenous caffeine has been shown to be effective and safe.  [Hunter, 2013]
  • Epidural blood patch has been shown to be effective for resolving symptoms in children and recommended if conservative therapies are not effective. [Kokki, 2012]

 

References

Bertolotto A1, Malentacchi M2, Capobianco M2, di Sapio A2, Malucchi S2, Motuzova Y2, Pulizzi A3, Berchialla P4, Sperli F2. The use of the 25 Sprotte needle markedly reduces post-dural puncture headache in routine neurological practice. Cephalalgia. 2015 Apr 23. PMID: 25908221. [PubMed] [Read by QxMD]

Monserrate AE1, Ryman DC2, Ma S3, Xiong C4, Noble JM5, Ringman JM6, Morris JC7, Danek A8, Müller-Sarnowski F8, Clifford DB3, McDade EM9, Brooks WS10, Darby DG11, Masters CL11, Weston PS12, Farlow MR13, Graff-Radford NR14, Salloway SP15, Fagan AM3, Oliver A7, Bateman RJ3; Dominantly Inherited Alzheimer Network. Factors associated with the onset and persistence of post-lumbar puncture headache. JAMA Neurol. 2015 Mar;72(3):325-32. PMID: 25622095. [PubMed] [Read by QxMD]

Khlebtovsky A1, Weitzen S2, Steiner I3, Kuritzky A3, Djaldetti R3, Yust-Katz S3. Risk factors for post lumbar puncture headache. Clin Neurol Neurosurg. 2015 Apr;131:78-81. PMID: 25725481. [PubMed] [Read by QxMD]

Davis A1, Dobson R, Kaninia S, Espasandin M, Berg A, Giovannoni G, Schmierer K. Change practice now! Using atraumatic needles to prevent post lumbar puncture headache. Eur J Neurol. 2014 Feb;21(2):305-11. PMID: 24320927. [PubMed] [Read by QxMD]

Jacobus CH1. Does bed rest prevent post-lumbar puncture headache? Ann Emerg Med. 2012 Feb;59(2):139-40. PMID: 21689866. [PubMed] [Read by QxMD]
Kokki M1, Sjövall S, Kokki H. Epidural blood patches are effective for postdural puncture headache in pediatrics–a 10-year experience. Paediatr Anaesth. 2012 Dec;22(12):1205-10. PMID: 23013060. [PubMed] [Read by QxMD]

Lee LC1, Sennett M, Erickson JM. Prevention and management of post-lumbar puncture headache in pediatric oncology patients. J Pediatr Oncol Nurs. 2007 Jul-Aug;24(4):200-7. PMID: 17588892. [PubMed] [Read by QxMD]

Arch Pediatr. 2005 Aug;12(8):1199-203. PMID: 16051072. [PubMed] [Read by QxMD]

Chordas C1. Post-dural puncture headache and other complications after lumbar puncture. J Pediatr Oncol Nurs. 2001 Nov-Dec;18(6):244-59. PMID: 11719905. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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