Management of Post-Lumbar Puncture Headache

Evidence Against Bed Rest After Lumbar Puncture

Systematic reviews of randomized controlled trials show that lying down shortly after the procedure has no significant effect on the risk of severe post-lumbar puncture headache compared to immediate mobilization (relative risk 0.98 [95% CI, 0.68–1.41]) 1
Bed rest is specifically listed as a practice "NOT proven to reduce risk of post LP headache" in clinical guidelines 2, 3, 4
Studies have demonstrated that prolonged rest by lying down after LP is not associated with lower incidence of adverse events compared to immediate mobilization 1, 5
A study conducted in 70 patients attending a neurology clinic found no significant difference in rates of post-LP headache between participants who laid down for 1 or 4 hours after the procedure 1

PDPH typically has a low-pressure phenotype (worse when upright, better when lying flat) and is usually caused by a dural tear sustained during the procedure 2, 3
The headache is not related to the volume of cerebrospinal fluid (CSF) taken during the procedure 2, 3
PDPH should be suspected if headache or neurological symptoms, which may be relieved when lying flat, occur within 5 days of a neuraxial procedure 6

Younger adults have a higher risk of PDPH 1, 7, 6
Female patients have a higher risk of PDPH 7, 6
Prior history of headaches may increase risk 6
Cutting bevel needles have higher complication rates than atraumatic needles 1, 5
Larger gauge needles (≤22 gauge) increase complication rates 1, 5, 2
Risk approximately doubles when two to four attempts are required and increases five-fold when five or more attempts are needed 1, 5

Use of atraumatic (non-cutting) needles 2, 6
Smaller gauge needles (though balanced with procedure time) 2
Orientation of the bevel in a transverse plane (perpendicular to the longitudinal axis) 2
Replacement of the stylet before withdrawing the needle 2
Fewer attempts at dural puncture 2
Gravity flow removal of CSF rather than active withdrawal with a syringe 1

Reducing the volume of CSF taken does not influence the incidence of post-LP headache 2, 3
Increased hydration shows no difference in PDPH rates between those who took 1.5L versus 3L post-LP 2, 4
Caffeine has been used to treat PDPH but has no evidence for prevention 2, 4

If PDPH occurs, it is typically self-limiting, though some patients may require a blood patch for persistent headache 2

Keeping patients flat unnecessarily may increase hospital stay without clinical benefit 1
Consider that younger patients and women are at higher risk for PDPH and may need closer monitoring 7, 6
Performing more than four attempts at dural puncture significantly increases PDPH risk 1, 5

The American College of Physicians recommends offering regular multimodal analgesia with acetaminophen and NSAIDs to all patients unless contraindicated, with an evidence grade of B 8, 9
Administering caffeine within the first 24 hours of symptom onset, with a maximum of 900 mg per day, is recommended, with an evidence grade of B 8, 9
Maintaining adequate hydration with oral fluids is recommended, with an evidence grade of C 8, 9

The American Society of Regional Anesthesia recommends epidural blood patch as the definitive treatment for persistent or severe PDPH, with a success rate of over 90% 8, 9
Greater occipital nerve blocks may be offered after spinal anesthesia with narrower-gauge needles, though headache may recur in a substantial proportion requiring subsequent EBP, with an evidence grade of C 9, 10

The American Society of Anesthesiologists recommends using noncutting (pencil-point) needles instead of cutting needles, with high certainty 8, 10
Using narrower-gauge needles when possible is recommended, with high certainty for cutting needles and moderate certainty for noncutting needles 8, 10
Minimizing the number of attempts is recommended 8, 10
Considering lateral decubitus position is recommended, with moderate certainty 8