NHS Borders clinical guidelines
The development of spinal headache is characterised by severe, disabling fronto-occipital pain with
radiation to neck and shoulders. There may be neck stiffness. The pain may be completely relieved by lying
supine. Although onset is commonly on the first or second day after dural puncture, it may occur on the
same day.
Management
Inform the consultant on call.
Exclude other causes of severe headache.
Document the PDPH by marking the appropriate boxes on the audit form & consult PDPH folder in Marie’s
office
Complete the PDPH form in Marie’s office and inform Dr Steve Alcorn or one of the other obstetric
anaesthetists (Dr Imogen Hayward, Dr Vanessa MacKenzie) or in their absence the COORD.
Unless there is a contraindication, prophylactic Dalteparin should be prescribed for 20:00 for the inpatient
stay – this will enable blood patch to be performed in the morning (i.e. 12 hours after LMWH) if required.
Discuss the problem and its management with the patient. Give her the PDPH information leaflet to read.
There are basically two options depending on how disabling the headache is:
Conservative management
Encourage oral fluids and simple analgesia: paracetamol, ibuprofen or diclofenac, dihydrocodeine (prescribe regular analgesics and an as required analgesic) unless contraindicated.
Recording of 4-hourly observations must be initiated.
Pharmacological management
Caffeine
There is limited evidence to support the use of caffeine. If used, the dose should be less than 300 mg, with
a total dose not exceeding 900 mg in 24 hours. For breastfeeding women, especially those with low birth
weight or premature babies, a total 24 hour dose of 200 mg should be considered.
It is difficult to provide accurate values for the caffeine content of drinks. As an approximate guide, a mug
of coffee will contain 65 – 160 mg of caffeine; an espresso will contain 45 – 100 mg. Coca cola® and Coke
Zero® contain 32 mg (in one can); Diet Coke® contains 42 mg per can. Tea contains 25 – 50 mg.
Other medication
There is insufficient evidence to support the use of other agents including theophyllines, steroids, triptans
and gabapentinoids.
Epidural blood patch
An epidural blood patch (EBP) should be considered when conservative management is ineffective and the
woman experiences symptoms which impair functions of daily living, including care of her baby. They must
be discussed with the consultant on call. Informed consent must be obtained.
Current evidence suggests that one third of patients receiving an EBP will experience complete and
permanent relief of symptoms. Complete or partial relief will occur in 50 – 80% of patients. In cases of
partial or no relief, a second EBP can be performed provided that other causes of symptoms have been
excluded.
The patient should be apyrexial – check the white blood count if indicated. Coagulation should be normal –
if on low molecular weight heparin, appropriate timing is essential (i.e. at least 12 hours following a
prophylactic dose or 24 hours following a treatment dose).
Although it has been suggested that efficacy may be improved by delaying epidural blood patch until 48
hours after dural puncture, this delay is not recommended as delay may increase the risk of serious
sequelae including subdural haematoma. The timing for performing the blood patch is at the consultant
anaesthetist’s discretion.
Epidural blood patch technique
Ensure patient is apyrexial and white count is normal on a recent FBC. A Tuohy needle is sited in the
epidural space overlying the puncture site or one interspace below using a standard epidural technique.
At least 20 mL of autologous blood are taken from the patient under sterile conditions.
20 mL of this blood are injected via the Tuohy needle into the epidural space. If the patient complains of
discomfort in her back or down her legs the injection should be stopped.
The patient lies flat for at least 2 hours (ideally 4 hours) and then mobilises gradually. She should be advised
to avoid vigorous activity and straining for several days.
The standard letter to the patient’s GP should be completed and uploaded to Badgernet. The patient should be given a Post Dural Puncture Information Leaflet (available in Marie’s office) and contact information for medical advice.
Follow-up is important and should as a minimum be done telephonically after one week and one month.
Severity – Lybecker scale of severity for PDPH
Mild (Score 1)
Postural headache with slight restriction of daily activities
Not bedridden
No associated symptoms
Responds well to non-opiate analgesics (Paracetamol, NSAIDs)
Unlikely to need Epidural Blood Patch
Moderate (Score 2)
Postural headache with significant restriction of daily activities
Bedridden part of the day
Associated symptoms may or may not be present
Requires the addition of opiate derivatives
Likely to need Epidural Blood Patch
Severe (Score 3)
Postural headache with complete restriction of daily activities
Bedridden all day
Associated symptoms present (photophobia, nausea, vomiting, tinnitus etc)
Not responsive to above conservative management
Should have Epidural Blood Patch