Development of Postdural Puncture Headache Following Therapeutic Acupuncture Using a Long Acupuncture Needle

Acupuncture appears to be a clinically effective treatment for acute and chronic pain. A considerable amount of research has been conducted to evaluate the role that acupuncture plays in pain suppression; however, few studies have been conducted to evaluate the side effects of the acupuncture procedure. This case report describes a suspected postdural puncture headache following acupuncture for lower back pain. Considering the high opening pressure, cerebrospinal fluid leakage, and the patient''s history of acupuncture in the lower back area, our diagnosis was iatrogenic postdural puncture headache. Full relief of the headache was achieved after administration of an epidural blood patch.     

Incidence of post-lumbar puncture headache is independent of daily fluid intake

Summary The clinical practice of advising patients to increase their daily fluid intake after lumbar puncture in order to increase CSF production by re-hydration and thus try to prevent post-lumbar puncture headache (PLPH) has not yet been shown to be effective. In 100 patients the different effects of re-hydration on the incidence of PLPH (1.51 compared with 3.01 oral fluid per day over a period of 5 days) were tested prospectively. The incidence of PLPH was independent of the amount of fluid intake in both groups (18, 36%), as was the duration of PLPH. The physiology of CSF production and resorption suggests that PLPH is not a problem of CSF dynamics but a simple mechanical problem of how to close the dural rent and thereby stop the continuous leakage. It is no longer justifiable to advise patients to drink more than usual since there is no physiological or empirical basis for this and it does not seem to have even a placebo effect.     

MMPI profiles in post-lumbar puncture headache

From the original material of 300 patients, of whom 37.3% had experienced a post-lumbar puncture headache (PPH), a total of 20 males and 50 females were evaluated with the Minnesota Multiple Personality Inventory (MMPI). The test was administered on average 33 months after the lumbar puncture (range 13–51), at a time when anxiety and depression related to the original investigation for a possible organic neurologic disease were expected to affect the results minimally. In the present material PPH was experienced by 45.7% of the patients, 40% of the males, and 48% of the females. Patients without PPH were used as controls. The selected material was a representative sample of the original material both as to distribution of age, proportion of organic diagnoses, and frequency of PPH. The MMPI disclosed no statistically significant differences between PPH patients and controls regarding personality traits.     

Natural history of headache in patients with lymphocytic meningitis following lumbar puncture

BackgroundAnalysis of cerebrospinal fluid (CSF) obtained by lumbar puncture (LP) is essential for diagnosis of meningitis. What is the impact of the procedure upon the natural history of headache and associated signs in patients with lymphocytic meningitis and what factors can have prognostic value for the future progression of symptomatology? This study was aimed at looking into these questions.MethodsOne hundred and one patients with clinical and laboratory diagnosis of aseptic meningitis answered a questionnaire intended at assessing the severity and nature of headache and meningeal irritation signs before and one, and twenty four hours after the LP. Later they were divided into three groups according to presence and type of headache after 24 h. Demographic and clinical data was obtained from patients files.ResultsThere was almost 50% improvement in headache severity and associated signs after 24 hours from LP in the whole group of patients. Patients that did not have pain after 24 hours had higher BMI and lower headache severity one hour after LP compared to patients in the other groups (p = 0.064 and p = 0.005). Patients with papilledema had higher incidence of post dural puncture headache (PDPH).ConclusionsOur study shows that patients with aseptic meningitis undergo improvement in all parameters of headache and also in signs of meningeal irritation following LP. Higher BMI and low headache intensity are positive prognostic factors for improvement of headache after 24 hours while papilledema is associated with a higher incidence of PDPH.     

Effect of pregabalin on post-dural-puncture headache following spinal anesthesia and lumbar puncture

In this study, we aimed to investigate the effect of pregabalin on post-dural-puncture headache (PDPH). Forty patients who developed PDPH after spinal anesthesia or diagnostic and/or therapeutic lumbar puncture were divided into two groups and followed for 5 days. The first group received 150 mg/day oral pregabalin for the first 3 days, then 300 mg/day for a further 2 days. The second group received a placebo for the same length of time. Patient headaches were scored using the visual analog scale, and diclofenac sodium and pethidine requirements were recorded. Relative to the placebo group, the group administered pregabalin had significantly lower visual analog scale scores after the second day of treatment, and had significantly lower diclofenac sodium requirements. Our results indicate that pregabalin may be useful for the management of PDPH.     

Is obligatory bed rest after lumbar puncture obsolete?

Summary After lumbar puncture (LP) an epidural CSF leakage caused by delayed closure of a dural defect leads to a decrease in CSF pressure. The resultant venous dilatation as well as downward shift of the brain with traction on pain-sensitive blood vessels and nerves frequently evokes post-lumbar puncture headache (PLPH), when the patient assumes the upright position. In previous studies differing opinions have been expressed about the prophylactic value of the posture taken by the patient after LP. The present study was designed to evaluate the benefit of the decrease of hydrostatic CSF pressure on the dural rent, when the patient lies down in a prone position with the head tilted down at an angle of 10° for 30 min immediately after LP: is it possible to accelerate the closure of the dural defect in this way and prevent PLPH? One group of patients (n = 78) lay in a prone position with the head tilted down at an angle of 10° for 30 min, the other group (n = 82) rose immediately after LP. PLPH was found to be independent of the posture in both groups and affected 44% and 41% of the patients, respectively, so that there is no longer any justification for requiring patients to remain in bed after LP.     

Atraumatic needle reduces the incidence of post-lumbar puncture syndrome

We investigated the occurrence of the post-lumbar syndrome (PPS) in relation to the puncture technique used, in a prospective randomised double-blind study comprising 100 patients. A new atraumatic 22-gauge cannula was compared with a 20-gauge cannula with a Quincke bevel. The atraumatic cannula is a needle with a tip shaped like a closed circular cone with a lateral opening, usually used with an outer cannula (introducer). The study showed that both the frequency of PPS and of acute complaints during lumbar puncture can be dramatically reduced with the atraumatic puncture technique. A marked PPS occurred after lumbar puncture with the 20-gauge cannula in 31% of patients, whereas only 5% of patients reported marked post-puncture symptoms after lumbar puncture with the atraumatic cannula.     

腰椎穿刺术后头痛与卧床时间的关系

目的探讨腰椎穿刺术后平卧时间30min、2h对头痛的影响。方法对794例具有腰椎穿刺术适应证而无禁忌证并排除有关因素的患者，随机分为30min组、2h组。分别观察术后头痛发生率。结果30min组头痛发生率为（8／460）1．74％，2h组为（7／334）2.10％，两组组间比较均无显著性差异（P〉0．05）。结论本研究说明腰穿后卧床时间长短（30min～2h），对腰穿后头痛的发生率无影响，可缩短至30min，没有必要卧床2h，更没有必要卧床4～6h。     

Post-dural puncture related complications after diagnostic lumbar puncture, myelography and spinal anaesthesia

Objectives – This study was conducted to investigate complications after dural puncture. Material and methods – A 15 months' prospective observation study of routine clinical practice with dural puncture at a university hospital was conducted. Quincke spinal needles 0.90 to 1.0 mm O.D. (20–19 g) were used for diagnostic lumbar puncture, 0.70 mm O.D. (22 g) for myelography and 0.40 to 0.50 mm O.D. (27–25 g) for spinal anaesthesia. A questionnaire about post-puncture discomfort was given to the patients, to be returned after 1 week. Results – Of 679 questionnaires 537 (79.1%) were returned. Discomfort was experienced by 53.8% of the patients, most often after diagnostic lumbar puncture and myelography. The difference in incidence of headache after diagnostic lumbar puncture and myelography compared with spinal anaesthesia were 27.9% (95% CI: 18.6 to 37.2) and 18.3% (95% CI: 9.1 to 27.5). Conclusion – Small diameter and atraumatic spinal needles will reduce patients' discomfort after dural puncture.     

A prospective double-blind clinical trial, comparing the sharp Quincke needle (22G) with an "atraumatic" needle (22G) in the induction of post-lumbar puncture headache

Posture-dependent, post-lumbar puncture headache is most likely caused by continuous leakage of cerebrospinal fluid through the dura mater perforation with a consecutive downward sagging of the intracranial content and an irritation of pain-sensitive structures of meninges and blood vessels. A psychogenic co-factor may also play a role. It is generally acknowledged that the incidence and intensity of the headache correlate significantly with the diameter of the needles used. A second factor, the shape of the needle point plays a crucial role as is shown in our prospective, double-blind, clinical trial with 75 patients: employment of the "atraumatic" Sprotte needle with a rounded off point significantly reduced the incidence of post-puncture headache from 36% to 4%. Beside the discussion of pathogenic factors, remarks on a rational therapy are made.     

Secondary chronic cluster headache due to trigeminal nerve root compression

Mjåset C, Russell MB * 1 [Correction added on 2 November 2010 after first online publication on 5 July 2010. The author name, “M. Bjørn Russell”, was amended to “M. B. Russell”.]
;. Secondary chronic cluster headache due to trigeminal nerve root compression.
Acta Neurol Scand: 2010: 122: 373–376.
© 2010 The Authors Journal compilation © 2010 Blackwell Munksgaard. A 50‐year‐old woman had a gradual onset of chronic headache located in the right temporal region and a burning sensation in the root of the tongue which over a year evolved into chronic cluster headache with a milder chronic headache in‐between the severe cluster headache attacks. A cerebral magnetic resonance imaging (MRI) showed vascular compression of the trigeminal nerve root on the pain side. Neurosurgery microvascular decompression relieved the patient?s chronic cluster headache, the chronic intermittent headache and the burning tongue sensation. The effect was persistent at a 1 year follow‐up. Patients with atypical symptoms of cluster headache should be examined with cerebral MRI angiography of arteries and veins to exclude symptomatic causes.     

硬币性头痛临床特点

目的观察和讨论硬币性头痛的临床表现。方法回顾性分析首都医科大学附属宣武医院神经内科门诊2006至2008年主诉头盖部圆形区域内疼痛患者共11例,对其头痛的临床特点进行分析,并行头MRI等辅助检查。结果所有病人辅助检查均未见异常,所有病人均为头部类圆形区域内疼痛,边界较清楚,头痛部位主要位于头顶部,疼痛部位和性质不随时间变化而变化。结论硬币性头痛有其特征性临床表现,但其内在机制有待进一步研究。     

Incidental Diagnosis of Cerebral Cortical Venous Thrombosis in Postdural Puncture Headache on Brain Computed Tomography

Diagnosis of cerebral cortical venous thrombosis in patients with postdural puncture headache (PDPH) is usually secondary to changes in headache pattern or cerebral infarctions. Nevertheless, incidental discovery of asymptomatic forms on brain imaging has never been reported before and its management thus remains ill‐defined. We describe 2 cases of patients with asymptomatic cortical vein thrombosis in the context of PDPH. In both cases, brain computed tomography (CT) scans showed an isolated cortical vein thrombosis without cerebral damage. Neurological examination revealed the typical orthostatic feature of PDPH, independently of cortical vein thrombosis which was considered as a radiological incidental finding. Clinical and radiological signs resolved after bed rest, oral caffeine, and anticoagulation therapy. Asymptomatic cortical vein thrombosis may be found on radiological exploration, even basic like brain CT scan without contrast, of PDPH. Utility of anticoagulation therapy, which could increase the risk of cerebral hemorrhagic complications in this specific context, has to be assessed.     

Paradoxical transtentorial herniation caused by lumbar puncture after decompressive craniectomy

Although decompressive craniectomy is an effective treatment for various situations of increased intracranial pressure, it may be accompanied by several complications. Paradoxical herniation is known as a rare complication of lumbar puncture in patients with decompressive craniectomy. A 38-year-old man underwent decompressive craniectomy for severe brain swelling. He remained neurologically stable for five weeks, but then showed mental deterioration right after a lumbar puncture which was performed to rule out meningitis. A brain computed tomographic scan revealed a marked midline shift. The patient responded to the Trendelenburg position and intravenous fluids, and he achieved full neurologic recovery after successive cranioplasty. The authors discuss the possible mechanism of this rare case with a review of the literature.     

Clinical categorization of 312 children with chronic headache

Three hundred and twelve children referred to an outpatient pediatric neurology clinic, with headache that lasted more than 3 months, were retrospectively reviewed. On average, the age of pain onset was 8.4 years. Migraine was diagnosed in 54% of these children and tension-type headache was found in 22% of those with chronic headache. Most children (85%) had common migraine, while classic and complicated migraine was found in only 8.8% and 5.3%, respectively. Brief headaches, lasting from seconds to a few minutes, were found in 5.1% of the children evaluated. In this subgroup, a high rate of epileptic EEG activity was found. Out of 110 children who had undergone computerized tomography, only one was pathological (posterior arachnoid cyst). Our results indicate that chronic and recurrent headache without accompanying neurological symptoms are usually benign and therefore in most cases neuroimaging is not indicated.     

Frequency and clinical characteristics of chronic daily headache in an outpatient clinic setting

Background and purposeChronic daily headache (CDH) is not a diagnosis but a category that includes many disorders representing primary and secondary headaches. According to the International Classification of Headache Disorders, 2^nd edition (ICHD-II), CDH is defined as headache which occurs more often than 15 days per month for at least 3 months.Material and methodsWe assessed 1154 headache sufferers diagnosed in our headache outpatient clinic. Clinical history, physical and neurological examination, and laboratory tests were performed to make a diagnosis.ResultsCDH was diagnosed according to ICHD-II in 185 (16%) patients; their mean age was 41 ± 17 years (80% were women). Chronic migraine was a cause of CDH in 49% (91/185) of patients, chronic tension-type headache in 18% (33/185), secondary headache in 25% (46/185) and unclassified pain in 8%. Medication overuse headache occurred in 15%. The most effective therapy in our patients was treatment with tricyclic antidepressants and selective serotonin reuptake inhibitors.ConclusionsThe most frequent cause of CDH in our cohort was chronic migraine. Women suffered more frequently than men. Antidepressants were the most effective preventive medications for all types of CDH, which may suggest that serotoninergic mechanisms can be an important factor in the pathophysiology of chronic pain syndromes.