So you just had an epidural or spinal, and are basking in the joy of your new baby, when suddenly you get up to use the restroom and realize you have a terrible headache… Unfortunately you may be one of the unlucky women experiencing a Post-Dural Puncture Headache (PDPH) or “spinal headache”. This month at the “Ask the Doctors” forum we review spinal headaches and specifically their causes and treatments… Don’t forget you can always ask questions about this or other medical topics through the “Ask a Question” link on the website located here.

What is a Post-Dural Puncture Headache (PDPH)?

A spinal headache can occur in anyone who has an epidural or spinal anesthetic. In fact, it can happen any time a hole is made in the “dura” (the tough layer of the tissue surrounding the brain and spinal cord. As we previously discussed on other “Ask the Doctors” topics the difference between an epidural and spinal is based on the location and the type of needle used to enter around the spinal cord space.

A post-dural puncture headache or PDPH, was first described by August Bier in 1898. Over the next 50 years the occurrence of PDPH was quite common, but as we have learned more about the causes of PDPH and with the introduction of much smaller pencil point needles the incidence of PDPH has decreased significantly.

If an epidural is being performed, the area before the spinal space or “epidural space” is entered to deliver medication. A larger needle is typically used for epidurals and if the spinal space in inadvertently entered (“wet-tap”), large amount of spinal fluid (cerebrospinal fluid) may leak out of the space and result in a “spinal headache”. When performing a spinal anesthetic, the “spinal” space is purposefully entered to deliver medication. A very small needle is used to limit the size of the hole and the amount of cerebrospinal fluid that can leak out of this space. Regardless of the technique (epidural or spinal) if cerebrospinal fluid leaks through the puncture site, there is an associated decrease in pressure that normally surrounds the brain and spinal cord. It is this decrease in pressure that is believed to be the cause for developing a “spinal” or “post-dural puncture headache” (PDPH).

What are the symptoms of a Post-Dural Puncture Headache (PDPH)?

Spinal headaches vary in intensity from mild to completely incapacitating, which can be quite frustrating when you’re trying to devote time and energy for your new baby. The headache is typically severe and throbbing and located in the front of the head radiating toward the back. The pain typically gets worse when you sit up or stand and decreases or goes away when you lie down. These headaches are frequently associated with other symptoms including photophobia, dizziness, neck stiffness, ringing in the ears, nausea, vomiting or changes in vision.

How is a Post-Dural Puncture Headache Diagnosed (PDPH)?

Ninety-nine percent of PDPH patients have symptoms within three days of their epidural or spinal, however most have a variable duration. A PDPH is typically diagnosed based on clinical history alone. The defining feature of a PDPH is the postural component of the headache (worsens with sitting or standing up and is relieved with laying flat). It is very important to also consider other possible causes for headache including caffeine withdrawal headaches, migraines, meningitis, sinus headaches, pre-eclampsia, drug use (amphetamine, cocaine), pneumocephalus-related headache, or possible intracranial pathology (hemorrhage, venous thrombosis).

What are the risk factors for a Post-Dural Puncture Headache (PDPH)?

The factors associated with an increase in the occurrence of spinal headaches are very common among pregnant patients. These include: younger age, female gender, pregnancy, using a larger needle size, the number of dural punctures (attempts at the spinal/epidural space in a current pregnancy) and the position in which the needle bevel is inserted.

The issue of whether a previous PDPH is a risk factor for a future PDPH in subsequent pregnancies is controversial. There is no data to support that if you developed a PDPH in a prior pregnancy, you are more likely to develop one in the future.

What is the treatment for a Post-Dural Puncture Headache?

The good news is that most spinal headaches resolve without treatment. However, a PDPH lasting more than 24 hours may require further care. Treatment of a PDPH begins conservatively and moves toward more aggressive measures. Some of these measures include lying in a comfortable position, hydration, and oral pain relievers. However, when symptoms do not improve with conservative measures an epidural blood patch (EBP) is considered the gold standard of treatment.

• Bed Rest – Although bed rest is advocated by many because symptoms generally improve by lying flat, there is no evidence to support using bed rest as a treatment for PDPH. Bed rest may simply be a mechanism to improve the severity of symptoms for those PDPH that resolve on their own.

• Caffeine – Caffeine is a stimulant that causes vessels in the brain to constrict, which has been previously shown in the medical literature to treat headaches. It is available in both oral and intravenous preparations. One of the problems with caffeine therapy is that relief of symptoms is usually not permanent. Another concern for caffeine supplementation during the early post-partum period is that caffeine can appear in breast milk, although usually in very small amounts.

• Sumatriptan – Sumatriptan is a medication currently available for the treatment of migraine headaches. Similar to caffeine, it is used to treat headaches by causing vessels in the brain to constrict. One of the limitations of this medication is its high cost and need to administer it subcutaneously.

• Epidural saline - Many have encouraged injecting saline into the epidural space (the space outside the membrane that covers your spinal cord) to cause pressure on the lumbar puncture site and stop the suspected cerebrospinal fluid leak. But because saline solution is absorbed so quickly by the body, spinal headaches often recur after this treatment. To date, there have been no research studies that show that this treatment actually raises this pressure or causes the suspected hole in dura to close more quickly.

• Epidural blood patch (EBP) - An epidural blood patch is the only treatment that has been shown to equivocally improve symptoms of a PDPH. The medical literature quotes a wide range of improvement after performing an EBP (65%-95%), however many women require a second EBP for complete resolution of symptoms. An EBP is performed by sterilely injecting a small amount of your blood into the epidural space. It is believed that this extra volume of blood will raise the pressure in the space and form a clot over suspected hole causing the leak in the cerebrospinal fluid (CSF). When an EBP is successful many symptoms disappear instantly, while it may take anywhere from 6-24 hours for symptoms to improve. There is always the risk however, of sustaining a second “wet-tap” during this procedure causing a worsening or prolongation of PDPH symptoms.

If you are one of the unfortunate women who are affected by a PDPH, I hope you find this entry useful. If you have any questions relating to this or other topics on “Ask the Doctors” please email them to askthedrs@thebumblecollection.com. Remember you can also submit a question to the website through the "Ask a Question" link.

See you next month!