Canadian Anesthesiologists' Society
Obstetric Section

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Suspected Postdural Puncture Headache:
Suggested Management of Parturients
Awaiting Evaluation by an Anesthesiologist
June 2001
 

Headache is a common finding in parturients following labour and delivery and may be related to multiple causes including dural puncture.(1) Postdural puncture headache is classically defined by the presence of headache worsened by sitting or standing and relieved in the supine position. It may be associated with neckache and less commonly auditory or ocular symptoms.(2) Variations in presentation may occur. Less common but serious conditions may also mimic postdural puncture headache.(3) Any patient with a moderate to severe headache, tinnitus, hearing loss, blurred vision/photophobia or postural headache following spinal or epidural anesthesia should be evaluated by an anesthesiologist.(4) 

Postdural puncture headache symptoms may require institution of therapy prior to the availability of anesthetic consultation. Initial conservative management by the attending physician should include:(5) 

• Bedrest as much as possible — in most patients lying in the supine or lateral position will provide complete symptomatic relief.
  

• Analgesic therapy should include regular administration of non-narcotic and narcotic analgesics (eg acetaminophen with codeine with backup parenteral narcotics for refractory symptoms) and non-steroidal anti-inflammatory drugs while awake.
  

• Encourage oral fluid intake including caffeinated beverages with a goal of maintaining normovolemia. Reserve intravenous hydration for patients unable to maintain hydration (eg severe nausea/vomiting) or for reasons not related to headache (eg bleeding).
  

• Advise the patient to avoid straining which not only worsens headache symptoms but may also increase cerebrospinal fluid leak through the dural puncture site, the source of the headache. Add a stool softener to the medical regimen.
  

• CONSULT ANESTHESIOLOGY! Around 60-70% of patients with postdural puncture headache after dural puncture with an epidural needle will require an epidural blood patch for symptomatic relief.(6)

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References

1.Benhamou D, Hamza J, Ducot B. Postpartum headache after epidural analgesia without dural puncture. International Journal of Obstetric Anesthesia 1995: 4; 17-20.

2.Brownridge P. The management of headache following accidental dural puncture in obstetric patients. Anaesth Intens Care 1983; 11:4-15.

3. Ravindran RS, Zandstra GC, Viegas OJ. Postpartum headache following regional analgesia: a symptom of cerebral venous thrombosis. Can J Anaesth1989; 36:705-7.

4. Dunbar SA, Katz NP. Failure of delayed epidural blood patching to correct persistent cranial nerve palsies. Anesth Anaig 1994;79:806-7.

5.Morewood Gil. A rational approach to the cause, prevention and treatment of postdural puncture headache. Can Med Assoc J 1993; 149:1087-1093.

6.Hunter GJ, Fogel St, Holtmann B. Accidental dural puncture in obstetrical patients: the failure rate of epidural blood patch. Society for Obstetric Anesthesia and Perinatology 1996: A188.

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