REPORT FROM THE AMERICAN ACADEMY OF NEUROLOGY (AAN) ANNUAL MEETING, PHILADELPHIA PA, APRIL 26-MAY 3, 2014 – Postdural puncture headache was first described over a century ago by Dr. August Bier, who pioneered spinal anesthesia (Bier A. Dt Zeitschr Chirung 1899;51:361-369). In Bier’s case, the procedure went terribly awry and his headache required bed rest for nine days.

Headache following lumbar puncture is common, reported to occur in up to 70% of patients (Waise & Gannon. Clin Med 2013;13:32-34). Various causes for postdural puncture headache have been proposed over the years, such as decreased CSF volume, an increased pressure difference in the spine and brain, and continued CSF leakage from the puncture site (Eversole & Rokowski. Calif Med 1954;81:59-64; Straus et al. JAMA 2006;296:2012-2022).

A study presented at AAN 2014 examined whether IV hydration before and after lumbar puncture reduces the occurrence of headache (Gupta et al. AAN 2014; abstract P1.260). A total of 62 patients underwent lumbar puncture with or without IV hydration (500 mL normal saline) given 30 minutes before and after LP. The incidence of post-LP headache was lower with versus without hydration (33.3% vs. 50.0%), but the difference was not statistically significant. However, there were differences in headache severity. Post-LP headache severity with hydration was mild in a majority of patients (78%) and severe in 11%. In contrast, headache was most commonly severe (69%) in patients who received no hydration.

Other studies have found that dural trauma and CSF leakage are more important factors in the development of post-LP headache (Dieterich & Brandt. Eur Arch Psychiatry Neurol Sci 1988;237:194-196). Thus, needle gauge (22G is recommended by the AAN), needle design (pencil-point vs. cutting), and injection technique (parallel to the long axis of the spine rather than perpendicular) may the more important factors affecting headache incidence (Waise 2013; Bezov et al. Headache 2000;50:1482-1498).

Guest Reviewer: Dr. Daniel Selchen, Head of Neurology, St. Michael’s Hospital, Toronto, Canada