Patient Presentation
A 9-year-old female came to the emergency room with headache, fever and nucal rigidity. A lumbar puncture was performed with results consistent with viral meningitis. After the lumbar puncture the patient’s headache seemed better when she was lying down but would get worse when she sat up or tried to walk. This was consistent over the next 3 days after which she was referred to a regional children’s hospital for evaluation and management. Upon admission, her fever had resolved after 24 hours and she was able to eat and drink, but intravenous fluids were maintained to ensure adequate hydration. Her headache was described as an occipital headache with some throbbing that occurred when she sat up. She denied vertigo and had minimal back pain at the lumbar puncture site. The family denied any medications other than what had been given in the hospital which included acetaminophen, ibuprofen and ceftriaxone which was stopped after cultures came back negative for bacterial meningitis. The past medical and family history revealed a fully-immunized child and were otherwise non-contributory. The radiologic evaluation from the outside hospital of an MRI of the spine was normal.
The pertinent physical exam showed a tired child in no distress lying in bed. Her vital signs were normal including blood pressure and growth parameters in the 10-25%. HEENT showed no papilledema. Her neurological examination revealed a patient who was alert and oriented x 4 with normal cranial nerves. Her DTRs were +2/+2 with normal strength and tone. Cerebellar maneuvers were normal. Her skin showed a small healing puncture over the lower spine.
The diagnosis of a post-dural puncture headache was made. After discussion with the family, the patient was treated with oral caffeine. Within an hour the patient was able to sit up and walk around the room without a headache. However after being up for about 4-5 hours, the headache returned. The headache resolved with lying recumbent. Caffeine was again given and the patient again was able to sit, walk and play. The headache again seemed to return after about 8 hours but was much less in intensity. Caffeinated beverages were then used along with some acetaminophen to maintain pain control. The patient went home after approximately 36 hours and on followup had complete resolution 2 days later.
Discussion
Post-dural puncture headache or spinal headache as they are often called, are headaches that occur within 7 days of a lumbar puncture and remit within 14 days of the lumbar puncture. They begin or worsen within 15 minutes of being in an upright position and improve or stop within 30 minutes of lying down. The headaches are described as a throbbing, dull and severe pain worse mainly in the occipital area, but can occur with radiation to the eyes, forehead or neck. Nausea, emesis, stiff neck, and visual or auditory changes may also occur. Most spinal headaches occur within 1-2 days of the lumbar puncture and spontaneously resolve after 5 days of headache (range 1-12 days).
The etiology is unknown but it is thought that the lumbar puncture allows a small cerebrospinal fluid leak to occur causing intracranial hypotension, downward sagging of the brain and subsequent pulling on the pain sensitive meninges and large blood vessels. Lumbar puncture techniques which may decrease the risk of spinal headaches include using a small gauge, non-cutting needle, orienting the bevel or opening of the needle parallel to the longitudinal dural fibers and replacement of the stylet before removing the needle.
Treatment usually begins with 1-2 days of supportive therapy including hydration, analgesics and bed rest. Medical treatment may include oral or IV caffeine. An epidural blood patch may also be attempted where ~10-15 ml of autologous blood is placed into the epidural space as close as possible to the lumbar puncture site. The success rate is 75-96%.
Learning Point
One prospective study of children ages 2-16 years showed 27% with some type of headache, 9% with a positional headache and 40% with backaches. Frequency of headaches increased with age, female gender in older patients and those with higher cerebrospinal fluid cell counts.
Other studies cite 2-15% occurence rate for spinal headaches.
Questions for Further Discussion
1. What are the classic cerebrospinal fluid findings for different types of meningitis? see What Are the Initial Cerebrospinal Fluid Findings in Differential Types of Meningitis?
2. Describe the key elements of informed consent?
Related Cases
- Disease: Headache
- Symptom/Presentation: Headaches | Fever and Fever of Unknown Origin
- Specialty: Emergency Medicine | Infectious Diseases | Neurology / Neurosurgery
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Headache
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Janssens E, Aerssens P, Alliët P, Gillis P, Raes M. Post-dural puncture headaches in children. A literature review. Eur J Pediatr. 2003 Mar;162(3):117-21.
Ebinger F, Kosel C. Pietz J. Rating D. Headache and Backache After Lumbar Puncture in Children and Adolescents: A Prospective Study. Pediatrics. 2004;113(6):1588 -1592.
St Noble V, Davagnanam I, Farmer S. Intractable headache after lumbar puncture. BMJ. 2011 Aug 8;343:d4529.
Kokki M, Sjövall S, Kokki H. Epidural blood patches are effective for postdural puncture headache in pediatrics–a 10-year experience. Paediatr Anaesth. 2012 Dec;22(12):1205-10.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 