Diagnosis of PDPH

¾ Headache develops within 14 days after dural puncture [22] .

¾ Patient has head or neck ache within 15 minutes of sitting/standing and is relieved within 15 minutes of lying down [22] .

¾ Patient has at least one of the following symptoms in association with the headache: neck stiffness, tinnitus, hypacusia, photophobia, or nausea [22] .

At time of accidental dural puncture

¾ Insertion of intrathecal catheter does not prevent PDPH, but does reduce the future need for epidural blood patch [34] - [36] . This is recommended if intrathecal catheters can be safely managed at your institution. (Ia)

Prevention of PDPH after accidental dural puncture

¾ If an epidural catheter is in place, two doses of 3 mg epidural morphine given 24 hours apart is recommended [34] [56] . (Ib)

¾ Consider giving a dose of 1 mg IV ACTH [57] [58] . (Ib)

¾ Consider giving a dose of 500 mg IV caffeine [51] [52] [55] . (Ib)

¾ Routine prophylactic epidural blood patch cannot be recommended [34] [35] [38] - [42] . (Ib)

Symptomatic treatment of PDPH within 48 hours of dural puncture

¾ Epidural blood patch within 24 hours of dural puncture is NOT routinely recommended. It may be even better to wait at least 48 hours [28] . (IIb)

¾ Treatment of symptoms with gabapentin 300 mg TID [62] - [64] or pregabalin 75 mg BID is recommended [65] [66] . (Ib)

¾ The recumbent position may be recommended to reduce symptoms, but strict bed rest is not necessary [45] - [48] . (Ib)

¾ Oral caffeine and aggressive hydration are NOT recommended [50] [51] [53] [54] . (Ib)

Treatment of PDPH after 48 hours post dural puncture

¾ An epidural blood patch should be offered to those with significant symptoms after 48 hours of dural puncture [28] [67] - [70] . (Ib)

¾ There is no ideal volume of blood for individual patients. Inject up to 20 ml or until patient feels pressure from the injection [28] . (IIb)

¾ A second blood patch should be offered if the first blood patch resulted in no relief or if symptoms return [28] [69] . (IIb)

¾ A head CT should be considered if patient has refractory headache despite receiving blood patches, altered mental status, or focal neurological defect [71] - [78] . (III)

Treatment of PDPH refractory to conventional epidural blood patch

¾ Consider head CT to rule out other causes of headache [71] - [78] . (III)

¾ Consider fluoroscopically guided and CT guided epidural blood patch [79] [80] . (III)

¾ Consider neurosurgery consult for surgical dura repair [81] . (III)