Post Dural Puncture Headache

• Venous sinus thrombosis
• Pre-eclampsia
• Meningoencephalitis
• Intracranial haemorrhage

Even if there is an obvious history 

• Tension Headache - dull, diffuse tightness around the head
• Migraine - classically throbbing unilateral pain +/- aura +/- nausea

Vascular problems

• Venous sinus thrombosis
• Subarachnoid haemorrhage
• Other intracranial bleed
• Stroke or ischaemia
• Dissection
• Posterior Reversible Encephalopathy Syndrome (PRES)
• Reversible cerebral vasoconstrictive syndrome
• Pituitary apoplexy

Non-vascular problems

• Post-dural puncture headache
• Benign intracranial hypertension
• Hypertension and pre-eclampsia
• Space occupying lesions
• Pneumocephalus

Infective problems

• Sinusitis - treat with antibiotics and decongestants
• Meningitis - fever, rigidity, mental status change
• Generalised sepsis

Pharmacological problems

• Caffeine withdrawal
• GTN and calcium channel blockers

• Paracetamol
• NSAIDs
• Sumatriptan

• Use a smaller needle 
• Pencil point needle rather than cutting bevel
• Re-insertion of stylet prior to removal of spinal needle
• Experienced operator
• Other techniques to improve first pass success - Optimal positioning and use of ultrasound

• Press on the abdomen under the right costal margin while patient is in a sitting position
• If this relieves the headache, this vaguely supports a diagnosis of PDPH
• It also suggests that an epidural blood patch may be effective

The idea is that the hepatic squeeze pushes blood into the epidural veins and squeezes CSF back up into the head.

You have to push really hard, it hurts, and probably doesn't add much to your rapport with an already distressed mother.

• Epidural blood patch remains the most effective treatment for a true PDPH
• Sphenopalatine ganglion block is another option, but not widely done in the UK

In case you're wondering, no you can't whack in a prophylactic EBP after ploughing through the dura and then siting the epidural a space higher. It doesn't work and just carries more risk.

Data suggest that complete, permanent relief of PDPH by a single blood patch occurs in 31%-50% of patients after puncture with an epidural needle, and up to 75% after a spinal needle. Complete or partial relief occurs in approximately 90% of patients.15–17 About 30% of patients require a second blood patch.

Preparation

• ID, informed consent, dedicated equipment, sterile set up, skilled assistance, monitoring as with any procedure we do
• Two anaesthetists, at least one senior and the other to do venepuncture
• (make sure venepuncture kit compatible with neuraxial kit, e.g. NRfit)

Procedure

• Locate epidural space with loss of resistance technique as per usual epidural technique
• Sterile venepuncture, aspirating 20ml autologous blood, remove venepuncture needle
• Inject blood slowly via Tuohy needle
• Stop when patient experiences back pain or they get symptomatic relief
• Remove Tuohy needle
• Lie patient down for 2 hours

Do not perform if patient febrile or has high white cell count.

Can cause transient bradycardia.

If it doesn't work, they need head imaging.

• Thought to cause vasoconstriction
• Dosage from 75mg to 500mg have been studied, both PO and IV
• Evidence was rubbish quality but suggested it might help
• You have to think about the cardiovascular and neurological side effects and consequences of telling a post-partum breastfeeding woman to take the equivalent of three red bulls a day
• Basically - if they already use caffeine, then continue to use it, but don't start smashing cans of Monster in the hope of ridding yourself of a headache it probably won't fix

Even if it does help with the headache, the newly-caffeinated raging steam-baby at three in the morning will probably cause another one.

• March 2017
• March 2013