Procedural Headache

Procedural headache is a type of headache that develops as a complication after certain medical procedures involving the spine, most commonly following a spinal tap or epidural anesthesia. This intense headache occurs when cerebrospinal fluid leaks through a puncture site in the protective covering of the spinal cord, causing pressure changes around the brain.

Table of contents

• What Is a Procedural Headache?
• What Causes Procedural Headaches?
• Symptoms and Characteristics
• Risk Factors
• How Is It Diagnosed?
• Treatment Options
• How Long Does It Last?

postdural puncture headache, post-dural puncture headache, spinal headache, epidural headache, low-pressure headache, PDPH

What Is a Procedural Headache?

A procedural headache, also known as a postdural puncture headache or spinal headache, is an intense headache that can develop after a medical procedure involving the spine^[2]. This type of headache happens when cerebrospinal fluid (the protective liquid that surrounds your brain and spinal cord) leaks out through a tiny hole created during a medical procedure^[3].

Your brain and spinal cord are normally cushioned by cerebrospinal fluid, which provides support and protection. When this fluid leaks out, the amount of fluid around your brain decreases. This causes the tissues and nerves that support your brain to stretch downward, resulting in headache pain^[3].

The condition is also sometimes called a low-pressure headache because the leakage causes low cerebrospinal fluid pressure around the brain, a condition known as intracranial hypotension^[2].

What Causes Procedural Headaches?

The most common cause of a procedural headache is a puncture created during a lumbar puncture (also called a spinal tap) or when receiving epidural anesthesia^[2]. Healthcare providers perform these procedures by inserting a needle into the spinal canal in the lower back.

During a lumbar puncture, a provider inserts a needle into the spinal canal to deliver anesthesia or to withdraw a sample of cerebrospinal fluid for testing. During epidural anesthesia, commonly used during childbirth and other medical procedures, the needle is placed near the spinal canal. Sometimes, the protective covering of the spinal cord (called the dura mater) is accidentally punctured during an epidural, leading to fluid leakage^[3].

The underlying cause of the headache is the intentional or inadvertent puncture of the dura during procedures necessary for diagnostic testing, delivery of medications into the spinal space, or administration of anesthesia^[2]. Other less common causes can include a ruptured cyst on the spinal cord, a tear in the protective covering of the spinal cord, or a head or face injury^[3].

Symptoms and Characteristics

Procedural headaches have very distinctive features that help identify them. The most characteristic symptom is that the headache pain changes with body position^[2].

Common symptoms include:

• An intense dull or throbbing headache that typically starts in the front or back of the head^[3]
• Headache pain that gets worse when sitting or standing up^[2]
• Pain that improves or goes away when lying down flat^[3]
• Headache pain that worsens when coughing, sneezing, or straining^[3]
• Nausea and sometimes vomiting^[2]
• Neck pain or stiffness^[3]
• Dizziness^[2]

Less common symptoms can include:

• Vision changes and sensitivity to light^[3]
• Ringing in the ears (tinnitus)^[2]
• Hearing loss or changes^[2]
• Tingling or numbness in the arms^[2]

Symptoms of a procedural headache typically develop within two to three days after the spinal procedure, though they can sometimes appear within five days or even develop months afterward^[3][2].

Risk Factors

Studies show that a spinal headache develops in approximately 10% to 40% of people who undergo lumbar puncture procedures^[3]. Several factors can increase the likelihood of developing a procedural headache.

Personal risk factors include:

• Being dehydrated^[3]
• Having a systemic illness (conditions that affect the whole body, such as high blood pressure or the flu)^[3]
• Having a history of headaches^[3]
• Having a low body mass index^[3]
• Being between 20 and 40 years old, particularly when receiving epidurals during labor^[3]

Procedure-related risk factors include:

• The size of the needle used during the procedure. Larger needles create bigger holes, making fluid leaks more likely^[2]
• The design of the needle. Certain needle types cause less damage to the protective covering of the spinal cord^[2]
• The number of puncture attempts. Multiple attempts increase the risk of leakage^[2]

How Is It Diagnosed?

Healthcare providers diagnose procedural headaches primarily based on your medical history and symptoms^[5]. If you have recently had a spinal procedure and develop a headache that lasts 24 hours or longer, the diagnosis is often straightforward. In that case, you usually do not need additional tests^[3].

During the evaluation, your provider will ask questions about your headache and perform a physical examination. It is important to mention any recent procedures, particularly a spinal tap or spinal anesthesia^[5].

In some cases, particularly if the headache presentation is unusual or symptoms persist despite treatment, your provider may recommend imaging tests. A magnetic resonance imaging (MRI) scan may be ordered to rule out other causes of your headache, such as tumors, bleeding in the brain, or other brain and nervous system conditions^[5][2].

Treatment Options

Most procedural headaches resolve on their own within one to two weeks, though some cases require treatment^[2]. Treatment approaches range from simple conservative measures to more invasive interventions depending on the severity of symptoms.

Conservative Treatment

Treatment for procedural headaches typically begins with conservative measures^[5]. Your healthcare provider may recommend:

• Bed rest: Lying flat allows your body to rest and can help reduce symptoms. Your provider may recommend bed rest for a day or two^[5]
• Increased fluids: Drinking plenty of fluids helps boost cerebrospinal fluid pressure. In cases of severe dehydration, intravenous fluids may be given^[5]
• Caffeine: Consuming caffeine-rich drinks can help narrow blood vessels and reduce blood flow to the brain, which may provide pain relief^[5]
• Pain relievers: Over-the-counter pain medications can help alleviate symptoms. Your healthcare provider may also prescribe stronger medications for more severe headache symptoms^[5]

Epidural Blood Patch

If your headache has not improved within 24 hours, or if conservative treatments are not providing relief, your provider might suggest an epidural blood patch^[5]. This is the usual treatment for persistent spinal headaches that do not resolve on their own^[5].

During this procedure, a small amount of your own blood is injected into the space over the puncture hole. The blood forms a clot that seals the hole, restoring normal pressure in the spinal fluid and relieving your headache^[5][2].

Alternative Treatments

In cases where multiple epidural blood patches fail to provide relief, other treatment options may be considered. Some medical literature mentions medications such as gabapentin, hydrocortisone, or cosyntropin as potential alternatives, though research on these treatments is limited^[13].

How Long Does It Last?

Spinal headaches typically last from a few hours to a few days, but can last longer in some cases^[3]. While procedural headaches usually resolve spontaneously within two weeks, symptoms may be severe enough to interfere with daily activities^[2].

You should see your healthcare provider if your symptoms continue for more than 24 hours^[3]. Though most cases resolve with treatment, rare complications can occur, including bleeding around the brain (intracranial subdural hematoma), which may require further evaluation^[2].