Headache After a Lumbar Puncture (Post-Dural Puncture Headache)

What a post lumbar puncture headache is

A lumbar puncture (spinal tap) uses a needle passed between the bones of the lower back into the sac of fluid around the nerves. The same space is entered for a spinal anesthetic, and it can be entered by accident during an epidural for labor (a "wet tap"). The tough outer membrane is called the dura, which is why doctors also call this a post-dural puncture headache (PDPH).

The hole in the dura can keep leaking cerebrospinal fluid (CSF) for days. Fluid is lost faster than the body replaces it, so CSF volume and pressure fall.

Why the headache is worse on movement and standing

CSF normally cushions the brain so it floats. With less fluid, the brain sags slightly when you are upright. That pulls on pain-sensitive membranes, veins and nerves at the base of the skull. The body also widens blood vessels in the head to make up for the lost volume, which adds a throbbing component. Lying flat removes the downward pull, so the pain eases. Coughing, straining, bending or shaking the head make pain worse because they shift fluid and pressure.

Symptoms (PLPH symptoms)

The International Headache Society defines it as a headache within 5 days of a dural puncture, caused by low CSF pressure, that usually comes with neck stiffness or ear symptoms.

• Postural headache: the defining feature. It builds within minutes of sitting or standing and fades within minutes of lying down.
• Location: usually the front of the head, the back of the head and neck, or both.
• Neck stiffness or pain and shoulder ache.
• Nausea and sometimes vomiting.
• Hearing changes: muffled hearing, ringing (tinnitus) or a blocked feeling, from pressure changes in the inner ear.
• Sensitivity to light and sometimes dizziness.
• Double vision, uncommonly, if the nerve that moves the eye outward (the sixth cranial nerve) is stretched. This needs prompt review.

How long does it last?

Most post lumbar puncture headaches start within 24 to 48 hours and settle on their own within 7 days as the hole seals. Some last up to 2 weeks or, rarely, longer. Severe headaches after an accidental puncture with a large epidural needle tend to last longer and are more likely to need a blood patch.

Risk factors

Bed rest after a lumbar puncture does not prevent the headache, and neither does drinking extra fluids beforehand. The needle type matters most.

How it is diagnosed

The diagnosis is usually clear from the story: a recent dural puncture and a headache that clearly changes with posture. A doctor will examine you to check for fever, neck stiffness from infection, and any nerve problems.

Tests are needed only when the picture is unusual: the headache is not postural, there is fever, confusion or new neurological signs, or it does not improve as expected. Then an MRI of the brain may show signs of low pressure (such as thickened, enhancing meninges or a sagging brain) and rule out bleeding, a subdural hemorrhage or cerebral venous thrombosis, both of which can follow a puncture in rare cases. After childbirth, doctors also consider preeclampsia and migraine.

Post lumbar puncture headache treatment

First steps (conservative treatment)

• Lie flat as much as you need to for comfort. This relieves symptoms but does not speed healing.
• Fluids: keep well hydrated, but extra fluids beyond normal needs have not been shown to help.
• Caffeine: coffee, tea or caffeine tablets narrow the widened blood vessels in the head and can ease the headache for a few hours. Avoid large amounts if you are breastfeeding, have heart rhythm problems or are prone to seizures.
• Simple painkillers: acetaminophen (paracetamol) and ibuprofen, at the label dose. Avoid ibuprofen if you have kidney problems, stomach ulcers or take blood thinners.
• Anti-sickness medicines for nausea, from your doctor.
• Avoid straining (treat constipation) and heavy lifting while the headache lasts.

Doctors sometimes use other medicines such as gabapentin, theophylline or nerve blocks at the back of the head (occipital or sphenopalatine ganglion blocks), but the evidence is mixed.

Epidural blood patch

An epidural blood patch is the most effective treatment. It is offered when the headache is severe, stops you functioning, or has not improved after 24 to 72 hours of conservative care.

1. An anesthetist places an epidural needle in the back, at or near the level of the original puncture.
2. At the same time, about 15 to 20 ml of your own blood is drawn from a vein in the arm under sterile conditions.
3. The blood is injected slowly into the epidural space until you feel back pressure or fullness.
4. You lie flat for 1 to 2 hours afterward.

The blood compresses the dural sac, quickly raising CSF pressure, then clots over the hole to seal it. Many people feel relief within minutes to hours. It works permanently in most people after the first patch. A second patch is sometimes needed. Side effects include back ache for a few days, and rarely infection, nerve irritation or another dural puncture.

Complications

Complications are rare but include:

• Subdural hematoma: bleeding between the brain and its covering from stretched veins. A warning sign is a headache that loses its postural pattern.
• Cranial nerve palsies: double vision or hearing loss, which usually recover.
• Chronic headache if a leak persists. Persistent leaks are managed like a CSF leak from other causes.
• Infection: meningitis or an epidural abscess is very rare but must not be missed if fever develops.

Prevention

• Atraumatic (pencil-point) needles and the smallest practical needle size are the most effective measures for diagnostic lumbar punctures and spinal anesthetics.
• An experienced operator who needs fewer attempts reduces risk.
• If an accidental puncture happens during an epidural, the team may thread a catheter into the spinal space for a period, which may reduce the chance of a severe headache.

Frequently asked questions

Why is a headache after lumbar puncture worse with movement?

Leaking spinal fluid lowers pressure around the brain. When you sit, stand or move your head, the brain sags slightly and tugs on pain-sensitive membranes and veins. Coughing and straining shift pressure further. Lying flat removes that pull, which is why the headache eases within minutes of lying down.

How long does a spinal headache last?

Most post lumbar puncture headaches begin within 2 days and resolve within a week without treatment, as the needle hole seals. A few last 2 weeks or longer, especially after a puncture with a larger epidural needle. A blood patch usually ends the headache within hours.

What is the best treatment for a post lumbar puncture headache?

Mild headaches are treated with lying down, fluids, caffeine and acetaminophen or ibuprofen. An epidural blood patch is the most effective treatment for severe or persistent headaches, relieving symptoms in most people after one procedure. Bed rest does not shorten the headache.

Which features are characteristic of a spinal headache?

A spinal headache is typically present when sitting or standing and eases after lying down. It begins within 5 days of the puncture and usually lasts days rather than weeks. Some people need a blood patch. It does not affect the majority of people who have a lumbar puncture.

How common is a headache after a lumbar puncture?

It depends on the needle. With traditional cutting needles, roughly 1 in 10 people develop one, with higher rates in young women. With fine pencil-point needles, the risk falls to a few percent. After an accidental puncture with an epidural needle, more than half get a headache.

When should I worry about a headache after a spinal tap?

Get urgent care if the headache comes with fever, a stiff neck, confusion, seizures, double vision, new leg weakness or numbness, or loss of bladder control, or if it stops changing with position. These can point to infection, bleeding or a blood clot rather than a simple leak.