A spinal headache, also known as a postdural puncture headache, is a complication of needle insertion into the subarachnoid space through the dural sac. The dural sac encases the spinal cord and cerebrospinal fluid.
This is a pressurized system that extends from the intracranial cavity down to the sacrum. Fluctuation in pressure can result in headache. This commonly occurs after diagnostic lumbar puncture. It is a less common complication of spinal anesthesia and spinal interventional pain injections.
Many people have an epidural or spinal injection for surgery or childbirth. Uncommonly, a certain type of headache can develop after an epidural or spinal injection.
This is called a post dural puncture headache. This leaflet explains the symptoms, the cause and the treatment of this type of headache.
What kind of headache is it?
Headaches after surgery or childbirth are very common. A post dural puncture headache is an unusual and specific kind of severe headache which can only happen after an epidural or spinal injection. It can be felt at the front or the back of the head.
It is worse when sitting or standing and it gets better when lying down flat. There may also be neck pain, sickness and a dislike of bright lights.
Some patients describe it as like a very bad migraine, which is made worse when sitting or standing up. It is most likely to start between one day and one week after the spinal or epidural injection.
Young patients and women having the spinal or epidural for childbirth are more likely than other people to have a post dural puncture headache.
What causes the headache?
Your brain and spinal cord are contained in a bag of fluid. The bag is called the dura and the fluid is called the cerebrospinal fluid (CSF).
For an epidural, a needle is used to inject local anaesthetic just outside the dura. If the needle accidentally passes through the dura, a small hole is made, through which CSF can leak out.
When a spinal injection is given, a very fine needle is inserted through the dura deliberately. Although the hole made by a spinal needle is exceptionally small, in some people this can still lead to leakage of CSF.
If too much fluid leaks out through the hole in the dura, the pressure in the rest of the fluid around the brain is reduced. This causes the typical headache.
If you sit up, the pressure around your brain is reduced even more. This lowered pressure makes the headache worse.
What Symptoms Should I Be Aware Of?
Spinal headache is usually debilitating and interferes with normal function and daily activity. Individuals may complain of associated symptoms such as nausea, vomiting, visual disturbance, and dizziness.
These symptoms manifest within 3 days in 90 percent of cases after needle insertion into the spine. Symptoms 5 days post procedure and immediately post procedure are rare.
Patients often complain of severe headache when sitting up or standing. Headache will virtually disappear while lying down. This is the hallmark sign of a spinal headache.
What can be done about the headache?
Lying flat as much as you can will help.
You should take a simple pain relief drug, such as paracetamol. You can take ibuprofen as well, providing you are not intolerant of it. Your doctor can advise you if it is safe to take ibuprofen, or you can check the information in the patient information leaflet supplied with the tablets.
You should also drink plenty of fluid. Caffeine drinks such as tea, coffee or cola are especially helpful. You should avoid heavy lifting and straining.
What are my choices if the headache persists?
Although the hole in the dura will usually seal over in a number of weeks, it is not usually advisable to wait for this to happen.
The brain is cushioned by the CSF around it. If the headache is left untreated, this cushioning is not present and it is occasionally possible for bleeding to occur into or around the brain (a subdural haematoma).
Very occasionally a fit (seizure) can happen. Your anaesthetist can explain more about these events.
A post dural puncture headache is therefore frequently treated with an epidural blood patch.
How Can Spinal Headache Pain Be Treated?
The goal of treatment is to restore pressure and replenish cerebrospinal fluid. Treatment options can be divided into both conservative and minimally invasive. Several key points about spinal headache treatment are as follows:
- Up to 85 percent of headaches will resolve within 6 weeks.
- Supportive care involves rehydration and analgesics.
- Caffeine can also help reduce headache severity.
- Bed rest is not an effective form of treatment.
- The gold standard of treatment is an epidural blood patch.
What to expect if you’re treated with an epidural blood patch: This is a minimally invasive procedure in which a spinal needle is introduced into the epidural space and the patient’s own blood is injected into the spine.
This helps occlude the spinal fluid leak, once clotted and helps equilibrate intracranial pressure.
Initial relief is felt due to the compression of the dural sac after introduction of blood. Use of autologous blood acts as natural “spackling”, helping to patch the leaking dura.
An epidural blood patch is a safe and effective procedure used to treat spinal headaches and has been employed since the 1960’s; it is still considered the standard of care for post dural puncture headache.
Other causes of severe headache after childbirth
If you have a severe headache after having a baby, there are other causes for severe headache that your doctors need to consider. Some of these headaches are very serious and require immediate treatment.
All severe or persistent headaches after childbirth should be reported immediately to the obstetric team for further investigation and appropriate management.
If the headache is associated with drowsiness, confusion or vomiting, this should be regarded as a medical emergency. Please contact your GP or hospital immediately, or call the emergency services.