Post Dural Puncture Headache (PDPH)


  • Onset within hours to days after dural puncture (66% within 2 days, 90% within 3 days, but case reports up to 12 days later)
  • Cardinal feature of the headache is postural nature – improves with recumbency and worsens with sitting/standing
  • Headache is usually bilateral, can be frontal and/or occipital. Associated features include neck/back stiffness, nausea/vomiting, dizziness, visual changes, photophobia, tinnitus, hypoacusia. 
  • Etiology thought to be the loss of CSF through disruption of dura and decreased intrathecal pressure, leading to traction pain on sensitive meningeal structures and adenosine mediated cerebrovasodilation
  • Incidence depends greatly based on size and type of needle used (ie 50-80% with 17g Tuohy, 1-2% with 27g pencil point)
  • Patient risk factors: younger age, female gender, low BMI, pushing time (obstetric patients)
  • Equipment risk factors: larger needle, cutting needle (Quincke)
  • Typically improves on its own withing 4-7 days

Clinical Challenges and Special Considerations

  • DDx for headache is broad - must always consider other etiologies, especially those related to the disease/process that necessitated the iatrogenic dural puncture and rare complications of dural puncture/PDPH such as subdural hematoma (from ruptured bridging veins) and cerebral venous thrombosis
  • Focal neurological deficits can occur with PDPH but are rare and should lead the practitioner to question diagnosis and consider head imaging
  • Of cranial nerve deficits with PDPH, CN VI (abducens) is most common and presents with double vision. Involvement should prompt consideration for urgent blood patch. 
  • Decision on whether to offer/proceed blood patch can be challenging. Patients should be counseled about natural course, conservative treatment options (see below), and risks of the blood patch including of worsening headache with accidental dural puncture.

Clinical Recommendations

- Conservative treatments with evidence of effectiveness: NSAIDs, Acetaminophen, opioids, caffeine, abdominal binders (uncomfortable, so rarely used), 

- Treatments with conflicting evidence of effectiveness: triptans, ACTH analogs (ie cosyntropin)

- Treatments withOUT evidence of effectiveness: Bed rest (postpones, but does not decrease intensity or duration of HA), Hydration (helpful if patient is dehydrated, but excess fluid intake does not increase CSF production). 

- Epidural blood patch remains treatment of choice in severe headache or cranial nerve involvement 

- Thought to work by tamponade effect on intrathecal sac increasing intrathecal pressures, as well as promoting healing of dural tear.

- Injected epidural blood spreads in both directions but primarily cephalad

- 15-20mL thought to be sufficient, some evidence that more than 20 has some benefit if patient can tolerate.

- trials with epidural saline show only transient effect, not as effective as blood

- 75% - 95% get relief from blood patch. 20-30% may require second patch.

- Common practice to have patient lay recumbent for 1 hour after blood patch to increase effectiveness, though evidence is lacking

- If first blood patch is ineffective, should reconsider other causes of headache

- Common complications of blood patch: back and neck pain, usually relieved with NSAIDs

- Rare complications of blood patch: arachnoiditis, spinal subdural hematoma, decreased mental status or seizures, transient bradycardia, transient CN VII palsy, high spinal (if effects of local anesthetic have not completely worn off)


Leibold RA, Yealy DM, Coppola M, Cantees KK. Post‐dural‐puncture headache: characteristics, management, and prevention.  Ann Emerg Med 1993, 22

Scavone, B. Post Dural Puncture Headache and Epidural Blood Patch. Virtual Grand Rounds in OB Anesthesia, March 2017.

D. K. Turnbull, D. B. Shepherd, Post‐dural puncture headache: pathogenesis, prevention and treatment, BJA: British Journal of Anaesthesia, Volume 91, Issue 5, November 2003, Pages 718–729,

Guglielminotti J, Landau R, Li G. Major Neurologic Complications Associated With Postdural Puncture Headache in Obstetrics: A Retrospective Cohort Study. Anesth Analg. 2019 Nov;129(5):1328-1336.

Harrington BE, Schmitt AM: Meningeal (postdural) puncture headache, unintentional dural puncture, and the epidural blood patch. A national survey of United States practice. Reg Anesth Pain Med 2009;34:430–4