The American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) in association with the European Society of Regional Anesthesia and Pain Medicine (ESRA PM), the Society of Obstetric Anesthesiology and Perinatology (SOAP), the Association of Obstetric Anesthesiologists (OAA), the American Society of Spinal Radiology (ASSR) and The American Interventional Headache Society (AIHS) has developed consensus recommendations for the management of patients with postdural puncture headache. The document was published in JAMA Network Open.
Post-puncture headache should be suspected if pain or neurological symptoms appear within five days after the neuraxial procedure, the document says. Symptoms may subside when lying down. Experts named young age and female gender as risk factors for developing headaches after puncture.
To reduce the risk of post-puncture headache, experts recommend using non-cutting needles for lumbar puncture. If a cutting needle is used, it should be finer. It is also recommended to insert the needle with a bevel parallel to the long axis of the spine.
If the dural sac is inadvertently punctured during insertion of an epidural catheter, an intrathecal catheter can be inserted for anesthesia and analgesia. Routine insertion of an “epidural blood patch” is not recommended. Bed rest to prevent post-puncture headache is also not recommended. Prophylactic planned intrathecal or epidural administration of any drug is not indicated, nor is the prescription of systemic drugs.
To treat post-dural puncture headaches, experts recommend maintaining adequate hydration. If oral fluids are not sufficient, intravenous administration should be used. The use of abdominal banding or aromatherapy is not indicated. Multimodal analgesia with acetaminophen and nonsteroidal anti-inflammatory drugs is recommended for all patients with postdural puncture headache in the absence of contraindications. Short-term use of opioids is possible. Long-term administration of such drugs is not indicated. During the first 24 hours after the onset of symptoms, caffeine can be used at a maximum dose of 900 mg per day.
The use of acupuncture and blockade of the pterygopalatine ganglion is not indicated. It is possible to block the greater occipital nerve in patients after spinal anesthesia, but in the future the pain syndrome may resume and intensify. Spinal and epidural use of morphine is not recommended.
Brain imaging may be performed if non-orthostatic headache persists or develops after initial orthostatic headache or if headache occurs five days after dural puncture. In the presence of focal neurological symptoms, visual disturbances, changes in consciousness or the occurrence of convulsive states, especially in the postpartum period, urgent neuroimaging is necessary to identify alternative diagnoses.
If post-dural puncture headache is resistant to conservative treatment, as well as in the case of severe neurological symptoms (for example, hearing loss), the introduction of an “epidural blood patch” should be considered.