Virginia Anesthesia Services LLC New Recommendations for Postdural Puncture Headache (PDPH) - Virginia Anesthesia Services LLC

New Recommendations for Postdural Puncture Headache (PDPH)

Postdural puncture headache (PDPH) is a medical complication resulting from dural puncture during the administration of neuraxial anesthesia. It is directly caused by low cerebrospinal fluid (CSF) levels due to leakage.1 New recommendations developed by multiple medical societies aim to improve prevention and management of PDPH.

In 1898, the incidence of PDPH after spinal anesthesia was as high as 66%. Since then, with the widespread use of fine-gauge pencil-point spinal needles, the incidence has decreased to <10%, with significant variance depending on the type of procedure and patient involved.2 While severe headache is the predominant symptom in PDPH, a wide range of symptoms have been reported, including nausea, vomiting, neck stiffness, hearing difficulties, vertigo, dizziness, and visual disturbances.2,3 

Previous reviews on the prevention of postdural puncture headache were limited by reliance on data from small, underpowered studies that were largely inconclusive. In early 2024, experts from six prominent institutions (ASRA Pain Medicine, European Society of Regional Anaesthesia & Pain Therapy, Society for Obstetric Anesthesia and Perinatology, Obstetric Anaesthetists’ Association, American Society of Spine Radiology, and the American Interventional Headache Society) came together to devise new, comprehensive recommendations on the prevention of PDPH.3

The guidelines state that if patients encounter headaches or neurological symptoms within five days of undergoing neuraxial procedures, regardless of the patient’s history, PDPH should be suspected. Clinicians should urge their patients to report symptoms for thorough evaluation and early detection. Demographic vulnerabilities were underscored in the guidelines, as experts conclude older adults and women (including younger women) are at greater risk of developing PDPH.4

As for the procedure itself, the new recommendations advocate for the use of non-cutting spinal needles and smaller-gauge needles for lumbar puncture, which can significantly reduce the risk of PDPH. Additionally, the guidelines advise against the routine use of prophylactic epidural blood patching, acupuncture, or sphenopalatine ganglion blocks, citing insufficient evidence to support their use. They emphasize the need for cautious consideration of prescribed treatments based on platelet counts and coagulation abnormalities, as well as more conclusive data surrounding routine cranial imaging before epidural blood patching. Finally, the guidelines promote the necessity for patient education and continuous monitoring to gather evidence on whether PDPH is linked to chronic headaches, backaches, and depression.3

The new recommendations emphasize proactive risk assessment and reduction before procedures that involve or may involve dural puncture, highlighting factors such as needle type and size and patient characteristics that impact PDPH risk. The guidelines acknowledge different healthcare institutions may have different limitations.  

References

  1. Ghaleb, Ahmed. “Postdural Puncture Headache.” Anesthesiology Research and Practice, vol. 2010, Aug. 2010, p. e102967.  https://doi.org/10.1155/2010/102967
  1. Turnbull, D. K., and D. B. Shepherd. “Post-Dural Puncture Headache: Pathogenesis, Prevention and Treatment.” British Journal of Anaesthesia, vol. 91, no. 5, Nov. 2003, pp. 718–29. https://doi.org/10.1093/bja/aeg231
  2. Kumar Das, Dibash, and Pamela Flood. “Addressing Postdural Puncture Headache: Guiding Clinicians Through Diagnosis and Management.” ASA Monitor, vol. 88, no. 3, Mar. 2024, pp. 1–4. https://doi.org/10.1097/01.ASM.0001008220.31969.9a
  3. Amorim, Ja, and Mm Valença. “Postdural Puncture Headache Is a Risk Factor for New Postdural Puncture Headache.” Cephalalgia, vol. 28, no. 1, Jan. 2008, pp. 5–8. https://doi.org/10.1111/j.1468-2982.2007.01454.x