PDPHs

Post-dural puncture headache (PDPH) refers to a self-limited headache that develops after dural puncture, most commonly following lumbar puncture or spinal anesthesia. The pathophysiology involves leakage of cerebrospinal fluid through the puncture site, leading to intracranial hypotension and downward sagging of the brain. The resultant traction on pain-sensitive structures causes a predominantly positional headache.

Clinical features include onset within hours to days after the puncture, a throbbing or dull head pain that worsens when upright and improves when lying flat, often with neck stiffness, nausea, photophobia, and sometimes tinnitus or vertigo. Most PDPHs resolve spontaneously within a few days to weeks; however, symptoms can persist for longer in some cases.

Diagnosis is clinical; imaging is not routinely required but MRI can show pachymeningeal enhancement and brain sagging in more persistent cases. Distinguish PDPH from other causes of headache after a procedure, such as migraine or intracranial hemorrhage.

Prevention focuses on technique. Using atraumatic (non-cutting) needles, smaller gauge, and minimizing dural puncture attempts reduces risk. Adequate patient positioning and prolonged bed rest are not routinely recommended.

Treatment includes supportive measures—hydration, analgesics, and caffeine—though evidence is limited. For persistent or severe PDPH, an epidural blood patch is the most effective therapy, with reported success in a majority of cases after a single patch. Alternative treatments include epidural saline patch or other regional techniques.

Prognosis is generally favorable; most PDPHs resolve completely. Complications are rare but can include subdural hematomas, persistent headaches, or cranial nerve palsies.