A spinal headache, also known as a post-dural puncture headache (PDPH), is a severe headache that can occur after a lumbar puncture or spinal tap. This invasive procedure, which involves inserting a needle into the subarachnoid space around the spinal cord to collect cerebrospinal fluid, can cause leaks of cerebrospinal fluid and lead to intracranial hypotension.
Spinal headaches can be extremely painful and debilitating. However, with an understanding of the symptoms, causes, risk factors, and treatments, many patients can find relief. This article provides a comprehensive overview of spinal headaches, including how to identify them, what causes them, who is at risk, and how they are treated in 2024.
Symptoms of Spinal Headache
The primary symptom of a spinal headache is a severe headache that starts within 24-48 hours after a lumbar puncture. The pain:
- Is usually described as a very bad headache, the worst headache someone has ever experienced.
- Is throbbing or pounding.
- Is worsened by sitting or standing upright.
- Is relieved by lying down flat.
- Radiates from the neck to the front of the head.
- May feel better when drinking caffeine.
- Can be accompanied by nausea, vomiting, dizziness, ringing in the ears (tinnitus), blurred vision, neck pain or stiffness, and sensitivity to light and sound.
Spinal headaches feel different from other kinds of headaches like migraines. The positional nature of the pain is a key distinguishing symptom. If someone has a severe headache that improves only when lying down, it is likely a spinal headache.
The pain is a result of the change in pressure between the skull and spine caused by leakage of cerebrospinal fluid after a lumbar puncture. When upright, there is less fluid to cushion the brain, putting more pressure on surrounding nerves and tissues.
What Causes a Spinal Headache?
Spinal headaches are caused by an accidental dural tear that occurs during a lumbar puncture procedure, creating a hole or leak in the dura mater membrane that surrounds the spinal cord and brain.
This protective membrane contains cerebrospinal fluid (CSF). A dural puncture allows CSF to leak out of the membrane, reducing the fluid volume and pressure that cushions the brain. As a result, the brain sags within the skull, putting pressure on surrounding tissues and causing a positional headache when upright.
Risk Factors for Dural Tears
Certain factors can increase the risk of an accidental dural tear during a lumbar puncture, including:
- Patient factors: Older age, female sex, low BMI, prior lumbar spine surgery.
- Procedural factors: Less experienced provider, reuse of an introducer needle, multiple needle insertions.
- Anatomic factors: Spinal anatomy variations, scarring around the dura.
- Equipment factors: Larger needle gauge, beveled (cutting) needle tip.
When a lumbar puncture is performed carefully by an experienced provider using the best techniques, dural tears only occur 1-13% of the time. However accidental punctures still frequently happen, which then leads to spinal headaches in a significant number of patients.
Who Gets Spinal Headaches?
While anyone who undergoes a lumbar puncture is at risk, spinal headaches are more common in certain groups, including:
- Women– More than twice as many women experience spinal headaches compared to men. The reason is not entirely known but may be linked to sex differences in spinal anatomy.
- Individuals with low BMI– Very slender people with little fat surrounding the spinal column have a higher risk of dural punctures.
- Younger adults– Younger patients in their 20s to 40s tend to have higher CSF pressures, increasing the risk of leakage and headaches.
- Postpartum women– Women who have had epidurals for childbirth often get spinal taps to rule out meningitis if they develop a postpartum headache. Accidental dural punctures during epidurals put them at high risk.
- Patients with prior lumbar spine surgery– Scarring around the dura from earlier spine procedures can make the membrane harder to navigate.
Overall, spinal headaches occur in about 1 in 3 patients under the age of 40 after a lumbar puncture, compared to 1 in 10 over age 40. Women have a spinal headache rate of nearly 40%, versus just 25% in men.
Diagnosing a Spinal Headache
If a new onset of a severe positional headache occurs within days after a lumbar puncture, it is most likely a spinal headache. However, since many factors can cause headaches, a physician will perform a full evaluation.
Steps in diagnosing a spinal headache include:
- Medical history– The doctor will ask about the timing, description of the pain, associated symptoms, past lumbar puncture procedures, and any other recent events.
- Physical exam– A neurological exam will assess cranial nerves, reflexes, balance, coordination, weakness, or sensory changes. Heart rate and blood pressure will also be checked while lying down and standing.
- Imaging– If the history and exam suggest a spinal headache, no imaging is usually needed. But CT or MRI scans might be done to rule out other causes like hemorrhage or stroke.
- Lab tests– A CSF sample may be analyzed to look for evidence of a spinal fluid leak.
- Spinal tap– Rarely, a doctor may perform a second lumbar puncture and measure opening pressure while the patient is upright and lying down. A low upright pressure indicates a CSF leak.
- Epidurogram– This involves injecting dye into the epidural space with imaging guidance to pinpoint the location of a CSF leak.
Once a spinal headache diagnosis is made, the doctor will recommend treatments based on the severity of symptoms and whether conservative measures work.
Treating Spinal Headaches
Many spinal headaches resolve on their own within a week as the dural tear seals. However, treatments are often used to provide faster symptom relief. Options may include:
- Conservative Therapies
- Bed rest– Lying flat for 1-4 days allows gravity to reduce intracranial pressure and ease headache pain. Strict 24-hour bed rest provides the best results.
- Hydration– Drinking extra fluids helps restore spinal fluid volume. Caffeine is a mild diuretic that can be particularly helpful.
- Over-the-counter pain medication– Drugs like acetaminophen or NSAIDs reduce headache pain but don’t treat the underlying spinal fluid leak.
- Abdominal binder– Wrapping the abdomen with a binder when upright helps reduce spinal fluid pressure changes.
- Sphenopalatine ganglion block– This nerve block procedure numbs structures in the face to relieve headache pain.
- Epidural Blood Patch
If conservative measures don’t provide sufficient relief within 24-48 hours, then an epidural blood patch is typically administered. This common procedure involves:
- Injecting 15-20 mL of the patient’s blood into the epidural space, usually at the level of the lumbar puncture.
- The blood forms a clot to seal the dural tear, preventing further CSF leakage.
- Symptom relief starts within minutes as spinal pressure is restored.
- Complete resolution occurs in about 70% of patients after one blood patch, though some require repeats.
- Spinal Fluid Infusion
For persistent spinal headaches, CSF volume replacement may be used alongside a blood patch, including:
- Epidural saline infusion– Sterile saline is injected and held in the epidural space for 20-30 minutes before draining. This expands the epidural compartment to decrease intracranial traction.
- Intrathecal saline infusion– Saline is injected directly into the subarachnoid space to restore CSF volume and pressure.
- Fibrin glue injection– A mixture of fibrinogen and thrombin is injected into the epidural space to seal the membrane leak.
Preventing Spinal Headaches
While not all dural punctures can be avoided, providers can take steps to minimize risks of leaks and spinal headaches:
- Use small-gauge, pencil-point spinal needles.
- Limit needle insertion attempts to 1-2 tries.
- Perform careful insertion and removal of needles.
- Identify high-risk patients like young, thin women.
- Conduct ultrasound-guided procedures when available.
- Have most experienced providers perform difficult lumbar punctures.
- Use prophylactic epidural blood patch in very high-risk patients.
Patient positioning during and after the procedure, along with sufficient rest and hydration, can also lower the chances of developing a spinal headache.
Outlook for Spinal Headaches
Most cases of spinal headache resolve fully within 3-4 days after a conservative treatment trial. Blood patching successfully relieves symptoms about 70% of the time. Intrathecal saline injections have a slightly lower success rate of 50-60%.
Up to one-third of patients have some headache recurrence after initial treatment. But repeat blood patches, at intervals of several days, usually provide complete resolution.
Very rarely, spinal headaches can persist for weeks to months. Further diagnostic testing and advanced surgical repairs may be needed in these cases. However, over 90% of spinal headaches have eventual relief of symptoms when properly diagnosed and treated.
Conclusion
Spinal headaches are a common complication after lumbar puncture procedures, occurring in up to 40% of susceptible patients who experience accidental dural punctures. Though extremely painful, positional headaches caused by CSF leaks usually improve within a few days after conservative therapy and epidural blood patching. A proper technique during lumbar punctures, combined with appropriate treatment approaches, allows most cases of spinal headaches to fully resolve over time. Patients should speak with their doctor about ways to manage symptoms for the fastest relief.
Frequently Asked Questions
What is a spinal headache?
A spinal headache, also called a post-dural puncture headache, is a severe headache that occurs after a lumbar puncture or spinal tap. It is caused by an accidental dural tear that allows spinal fluid to leak out and reduce the cushioning around the brain. The main symptom is a throbbing headache that worsens with sitting or standing upright but improves when lying down flat.
Why do spinal headaches occur?
Spinal headaches happen after an accidental puncture during a lumbar procedure creating a hole or tear in the dura mater membrane containing cerebrospinal fluid around the spinal cord. This CSF leak causes decreased fluid pressure and volume, allowing the brain to sag and put pressure on surrounding nerves and tissues while upright.
How is a spinal headache diagnosed?
A diagnosis is made based on typical symptoms starting within 48 hours after a lumbar puncture, along with ruling out other potential causes. A CSF sample, epidurogram dye test, and spinal fluid pressure measurements may help confirm a leak. Neurological imaging usually isn’t required.
How are spinal headaches treated?
Most spinal headaches resolve on their own within a week. Initial treatment involves bed rest, fluids, caffeine, abdominal binding, and pain medications. If symptoms persist, an epidural blood patch is very effective at sealing the leak. Rarely, invasive procedures to replace lost spinal fluid may be needed for patients with severe, ongoing headaches.
What is an epidural blood patch?
An epidural blood patch is the most common procedure to treat a spinal headache. About 15-20 mL of the patient’s blood is injected into the epidural space to form a clot that seals the dural tear. This procedure immediately raises spinal fluid pressure and provides symptom relief in over 70% of patients.
How can you prevent spinal headaches?
While not every dural puncture can be avoided, proper technique during lumbar punctures reduces risk. Small gauge needles, limited insertion attempts, and experienced providers lower the chances of accidental tears. Patient positioning, hydration, and rest after the procedure are also beneficial.
What is the long-term outlook for spinal headaches?
Nearly all spinal headaches resolve within a few weeks at most with appropriate conservative treatment and epidural blood patches. Repeat patching results in complete symptom relief for over 90% of patients. Very rarely, spinal headaches may persist longer and require more invasive surgical repairs. But the vast majority of cases fully resolve with time.
Mustafa Al Mahmud is a passionate medical writer and health enthusiast. He is excited to share his knowledge and make reliable health information more accessible through Quick Medico. Mustafa aims to write about common diseases, medications, wellness topics, and the latest health research in easy-to-understand language. He believes clear and accurate health communication empowers readers to take charge of their well-being. In his free time, Mustafa enjoys hiking, cooking, and spending time with his family.
