Headache after dural puncture—risks and current treatments

Postdural Puncture Headache—Risks and Current Treatment Purpose of Review This manuscript aims to review the risks and the current treatments for postdural puncture headache (PDPH).
Risk and treatment status of piercing headache (PDPH)
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Recent studies have found that PDPH is a relatively common complication after axonal conduction block
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It is usually orthostatic and presents as a positional and dull pain or throbbing headache with additional dysregulation of auditory and/or visual signals
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Certain characteristics, such as female sex and young age, may predispose patients to the development of PDPH, as well as possible factors such as prior PDPH, stress during the second stage of labor, and the neural axis technique itself
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Long-term complications, including chronic headaches for many years after dural puncture, make the historical classification of PDPH a self-limiting headache
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To date, the underlying mechanisms controlling PDPH are still under investigation, while various preventive and therapeutic measures have been explored with varying degrees of success
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Summary: For mild PDPH, first-line treatment should be conservative, including bed rest and medical therapy
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Nerve blocks are a highly effective option for PDPH patients who do not respond well to conservative therapy
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Epidural blood patches remain the treatment of choice for moderate to severe PDPH
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An interdisciplinary approach to the care of patients with PDPH is recommended for optimal outcomes
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IntroductionPDPH Definition and Symptoms Postdural piercing headache (PDPH) is an orthostatic, dull pain or paroxysmal headache, typically characterized by intense fronto-occipital compression, accompanied by auditory and/or visual cues adjustment disorders [1]
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PDPH, usually caused by a recent (within 5 days) dural puncture, worsens sharply within 15 minutes of standing and mostly resolves within 15 minutes of supine [2]
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PDPH is often accompanied by neck stiffness and/or subjective hearing impairment
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Typically, symptoms resolve spontaneously within 2 weeks, or after placement of an autologous epidural clot to seal cerebrospinal fluid (CSF) leaks [3]
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It is worth noting, however, that atypical presentations lacking a postural component, with immediate or delayed onset or prolonged course, or with isolated shoulder or back pain radiating to the upper extremities, have been reported [4]
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PDPH is often associated with neural axis anesthesia procedures, but can also occur after diagnostic or therapeutic procedures, or after spinal interventional procedures [5-8]
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Among anaesthesia-related cases, PDPH is the most common in obstetric anaesthesia, with approximately 0.
7% of women receiving labor epidural or spinal anaesthesia, ultimately using PDPH, as well as neuroanaesthetics for pain relief [9, 10] ]
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In cases of interventional pain management, PDPH may occur after epidural steroid injection, spinal cord stimulation placement, and intrathecal intubation, and rarely after other interventional techniques [11, 12]
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The overall incidence of PDPH after spinal anesthesia has been reported to be 6-36% [13, 14]
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On the other hand, the incidence of PDPH following therapeutic epidural injections of steroids, spinal cord stimulation, and intrathecal cannulation for infusion interventions is unclear, although these procedures are usually performed
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The classic definition of PDPH is a diffuse, generalized orthostatic headache, usually located in the temporal or occipital region
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It is sometimes associated with nausea, hearing impairment, increased sensitivity to light stimuli, neck stiffness, and is exacerbated by physical exertion, coughing, and Valsalva maneuvers (Table 1)
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Patients may complain of "diplopia" due to stretch of the fourth and sixth cranial nerves [15]
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Typical sites for headaches are the forehead and occiput, with radiation from the neck and shoulders
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As described by Loures et al.
, PDPH can present as an atypical non-orthostatic headache
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5.
6% of the 142 mothers with PDPH
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These women present with stiffness and pain in the cervical, thoracic, or lumbar region, visual disturbances, and vertigo [4]
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PDPH usually occurs within a few days (usually 1-2 days) after dural puncture, and most commonly lasts 7-10 days
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PDPH developed or worsened within 20 s after standing, and reached its maximum intensity within 1 min
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Sitting or lying position can reduce or alleviate PDPH
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Historically, PDPH was considered self-limiting, usually healing spontaneously within 2 weeks after dural puncture, or by placing a leak seal with an autologous epidural blood patch
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However, a current prospective study, as well as some retrospective studies, have called into question the current International Headache Society's definition of PDPH as a self-limited headache
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Headache caused by dural puncture persists for at least 18 months in a large number of women in labor [21]
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MacArthur et al
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The first systematic study of the long-term sequelae of dural puncture
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They revealed that 17 women (23 percent) reported one or more headaches or migraine or neck pain that began shortly after dural puncture and lasted more than six weeks [22]
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In another retrospective cohort study, 40 accidental dural punctures and 40 controls were assessed for symptoms of headache and back pain 12-24 months postpartum
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Up to 28% of women in labor complain of persistent headache after a one-time dural puncture [23]
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A recent study by Niraj et al
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The first prospective and adequately powered study was conducted to assess the long-term consequences of dural puncture
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As expected, 58.
4% of the dural puncture group had chronic headaches at 18 months, compared with 17.
4% of the control group
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Based on these studies, it can be concluded that dural puncture is strongly associated with long-term morbidity, especially in laboring women
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Another intriguing long-term outcome of PDPH after dural puncture is chronic low back pain
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There is a strong, well-established relationship between headaches and low back pain, as demonstrated by multiple studies and a recent systematic review
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According to Niraj et al.
, inadvertent dural puncture increases the risk of low back pain at all time points - postdural destruction for up to 18 months [21]
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This is similar to the conclusion of Ranganathan et al
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and Weber et al
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studies [23, 25]
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Unfortunately, the mechanisms behind this link between PDPH and chronic low back pain remain unclear, possibly because of the heterogeneity of the study populations, which complicates identifying commonalities
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The obstetric population undergoing the same procedures that can cause PDPH and low back pain is fairly homogeneous, and this may be the best opportunity to study this topic in more detail
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Awareness of the long-term sequelae of a one-time accidental dural puncture has educational implications for trainees and clinical implications in workflow, including procedural informed consent
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That said, it is critical to discuss the long-term effects of an accidental epidural with the mother while obtaining informed consent for epidural analgesia in labor and the decision-making process
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The mechanisms, risk factors, and potential mechanisms for the prevention and treatment of acute PDPH are still under investigation
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In general, any iatrogenic injury to the dura may result in PDPH
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So far, there are three main pathways for the formation of PDPH [26-28]
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The first mechanism involves relaxation of the meningeal vessels following a reduction in cerebrospinal fluid pressure
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The second mechanism involves mechanical distraction of the intracranial nerves that respond to pain, namely the superior cervical, 5th, 9th, and 10th cranial nerves, once the patient is upright
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The last mechanism involves changes in compliance in the caudal and cranial regions of the central nervous system (CNS), resulting in intracranial hypotension
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Although the pathophysiology of acute PDPH may be multifaceted, similarities between these etiologies include cerebrospinal fluid loss associated with spinal fluid production [29]
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The reduced CSF volume is usually compensated by central venous dilation, which in turn produces the intense pressure sensation commonly seen in PDPH patients [30]
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Also, this explains the specific part of the headache
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Therefore, standing causes the central veins to dilate, creating postural pressure that can lead to severe headaches
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However, after lying down, the central vein size returned to normal and the headache improved significantly
.

Likewise, hypothesized mechanisms for retrodural injury in persistent and chronic headache include chronic low-grade dural leakage leading to persistently low CSF levels, persistent downward pull-down of structures responsive to intracranial pain, and/or compensatory vascularization of intracranial vessels Expansion [26-28]
.

Although the management of PDPH has been extensively studied using various forms of therapy, there is some conflicting evidence regarding recommendations, including bed rest, use of abdominal adhesives, and fluid supply after lumbar puncture
.

According to a systematic review, bed rest was not particularly beneficial for the prevention of PDPH compared with immediate activity after lumbar puncture
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However, it did reduce the severity of the headache to some extent [57]
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Likewise, abdominal adhesive has also been shown to relieve headaches by increasing pressure in the epidural space, although it is not practical in the postpartum period [57]
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Finally, there is no conclusive evidence for the potential benefit of prophylactic infusions to prevent PDPH [58]
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