Postdural puncture Headache (PDPH)
Parts of the figure by Servier Medical Art (https://creativecommons.org/licenses/by/3.0/)
What does PDPH mean?
Postdural puncture headache (PDPH) is a secondary headache, thus, a headache caused by a specific reason.
PDPH can occur when the tough outer membrane of the layer surrounding spinal cord, nerves, and CSF space (Dura) is punctured in the area of the lower back.
How is PDPH diagnosed?
Typically, this headache occurs within 5 days after intentional or unintentional puncture. However, later onset, chronic courses, and atypical clinical presentations have also been described and are often underestimated.
Most patients complain of a new headache, often located more in the back of the head and neck. These symptoms occur or worsen when standing up. When lying down, the discomfort significantly improves or even disappears completely.
In addition, there are many other various symptoms such as nausea, vomiting, dizziness, auditory and visual disturbances, sensory disturbances, sensitivity to noise and light, concentration difficulties, and many more.
Imaging is normal - does it mean I am imagining?
The diagnosis is established by the correlation between the onset of headaches with typical features and the puncture.
In some cases, changes in routine MRI can be observed (similar to SIH). A normal MRI does not rule out PDPH.
We still do recommend the following MRI examination in patients with refractory symtpoms:
Head MRI: 1mm MPrage post-contrast, axial 1mm CISS, or 2mm T2 fs over the orbits.
Spine MRI: At least 1mm 3D T2 SPACE fs over the lumbar spine.
How are the risks to develop PDPH?
The incidence of PDPH varies widely, depending on patient (e.g., age, sex, pregnancy, body mass index [BMI]) and procedural (e.g., needle size and type, bevel orientation for cutting needles) risk factors. The incidence of PDPH is between 3- 9 percent of cases, depending on the type and size of needle used.
PDPH is the most common complications of a lumbar puncture performed for diagnostic purposes. It also occurs after accidental dural puncture during routinely performed medical procedures like epidural pain relief for parturients, spinal regional anesthesia.
Predominantly PDPH is seen by unintentional dura puncture in providing obstetric anesthesia and analgesia in parturients.
The burden of chronic PDPH
Can PDPH be treated?
Yes, PDPH can be treated, and it should be treated.
A common problem is that PDPH is not treated early enough, nor adequately.
The frequency of chronic courses is underestimated.
Especially after epidural anesthesia (PDA) and childbirth, two patients suffer simultaneously: the mother and the child.
Rest, drink, wait?
If the symptoms do not improve promptly and significantly with the necessary immediate measures (pain therapy, fluids, lying down, caffeine), a sufficiently large-volume bloodpatch should be administered.
A blood patch can also be repeated if its effect is inadequate.
There are various other pain management methods, the evidence for which is not yet fully established, and they may be performed in addition based on the center's experience (analgesia of N. occipitalis, sphenopalatine block).
In rare cases where the basic treatment is ineffective, the remaining open leak might be closed through surgery.
Here, you can find guidelines for the treatment of PDPH.
You can read more information about our interdisciplinary CSF team, and find contact information here.
Additional informational materials and useful links can be found here.
Klinik für Neurochirurgie
im Neurozentrum
Breisacher Straße 64
D-79106 Freiburg
Telefon: 0761 270-50010 /-50020
Telefax: 0761 270-50240
neurochirurgie@uniklinik-freiburg.de
Prof. Dr. Jürgen Beck
Ärztlicher Direktor
Telefon: 0761 270-50060
International call: +49-761-270-50060
j.beck@uniklinik-freiburg.de
Susanne Hall
Pflegedienstleiterin
Telefon 0761 270-52260
Telefax 0761 270-54200
susanne.hall@uniklinik-freiburg.de
Moritz Wenk
Verwaltungsreferent
Augen- / HNO- Klinik / Neurozentrum
Telefon 0761 270-40650
moritz.wenk@uniklinik-freiburg.de