REVIEW

CURRENT
OPINION Postdural puncture headache: a headache for the
patient and a headache for the anesthesiologist
Robert R. Gaiser

Purpose of review
To identify newly identified risk factors for the development of a postdural puncture headache (PDPH) as
well as to outline the key points in the management of unintentional dural puncture and of PDPH.
Recent findings
The lack of experience of the proceduralist and a vaginal delivery are two risk factors that increase the risk
of the patient developing a PDPH. The use of intrathecal catheters for the prevention of a headache is not
of value, although an intrathecal catheter may prove to be the best method for providing analgesia for the
patient. When performing an epidural blood patch, the optimal amount of blood is 20 ml, as long as the
patient does not develop the symptoms of back pain or leg pain during the injection.
Summary
Many practitioners do not practice an evidence-based approach to the management of unintentional dural
puncture and PDPH. Written institutional protocols are important to insure that patients receive the optimal
care.
Keywords
epidural blood patch, intrathecal catheter, postdural puncture headache

INTRODUCTION pain and nerve damage increased, suggesting a

Postpartum headache remains a major problem to change in the patient’s expectations. The pro-
both the obstetrician and the anesthesiologist. portion of claims for headache was the same in both
Headache is one of the most common complaints periods, and was the third leading cause for the
of postpartum women. Typically, the anesthesio- filing of a malpractice claim, approximately 15%.
logist is contacted as it is felt that many postpartum Of the claims for headache, almost half result in a
headaches are a result of intrapartum neuraxial payment. These results are surprising: patients are
(spinal or epidural) analgesia. Stella et al. [1] filing lawsuits for a manageable complication and
examined 95 women who presented with a head- the lawsuits are successful 40% of the time.
ache within 24 h of delivery. The most common
types of headache were tension and migraine head-
POSTDURAL PUNCTURE HEADACHE
ache, contrary to the belief that the postdural punc-
ture headache (PDPH) is the most frequent cause in In diagnosing a PDPH, the International Headache
the postpartum period. In fact, preeclampsia was a Society has established four diagnostic criteria (see
more common reason for a postdelivery headache list below) [3]. The use of these criteria is extremely
(24 vs. 16%). These points must be emphasized to helpful in distinguishing a PDPH from other causes
obstetricians as one would not want to misdiagnose of headache such as migraine. PDPH is typically
a woman with preeclampsia.
The importance of appropriately diagnosing and
Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania,
managing a PDPH is emphasized by the American USA
Society of Anesthesiologists Closed Claims Analysis Correspondence to Robert R. Gaiser, MD, M.S.Ed., Professor of Anes-
database [2]. Obstetric anesthesia malpractice claims thesiology and Critical Care, Hospital of the University of Pennsylvania,
for injuries from 1990 to 2003 were compared to 3400 Spruce Street, Philadelphia, PA 19104, USA. Tel: +1 215 662
those from before 1990. The proportion of claims for 3773; fax: +1 215 615 3989; e-mail: [email protected]
maternal death and for newborn brain damage Curr Opin Anesthesiol 2013, 26:296–303
declined, whereas the proportion of claims for back DOI:10.1097/ACO.0b013e328360b015

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 Postdural puncture headache Gaiser

telephone call with a questionnaire, were completed

KEY POINTS 12–24 months after delivery. Twenty-eight percent
 The diagnosis of a postdural puncture headache of those who had a PDPH reported a chronic head-
includes symptoms of a positional headache and an ache compared with 5% in the control group. Within
accompanying symptom such as neck stiffness, tinnitus, the UDP group, five of the 25 patients who received
hypacusia, or photophobia. an EBP had a headache 1 year later compared with six
of the 15 patients who did not receive an EBP. These
 The use of an intrathecal catheter following UDP does
not prevent a postdural puncture headache. An results suggest that an UDP with a large-bore epidural
intrathecal catheter may be used to provide needle has significant consequences beyond the
intrapartum analgesia. initial headache period. Interestingly, an EBP was
associated with a lower incidence of chronic head-
 The optimal dose of blood for an epidural blood patch
ache, but did not prevent it.
is 20 ml, assuming the patient tolerates the injection
without back pain or leg pain. UDP may result in a headache that persists for
a long time. This fact is not surprising. In 1954,
 A written protocol for the management of unintentional Vandam and Dripps [6] investigated the long-term
dural puncture and of postdural puncture headache effects of spinal anesthesia. Spinal anesthesia with a
insures that the patient receives optimal care and may
16-gauge Quincke (cutting) needle resulted in per-
decrease the chance of a lawsuit.
sistence of headache beyond 6 months in 13% of
individuals. These results are consistent with the
study by Webb.
bilateral and may occur in the frontal, occipital, or As outlined by the International Classification
both areas. Although the International Headache of Headache Disorders, an accompanying symptom
Society states that a PDPH resolves within 1 week, must be present to confirm the diagnosis of PDPH.
this occurrence is based upon the assumption that Visual disturbances (diplopia) are because of dys-
the headache is the result of a dural puncture from a function of the extraocular muscles from palsies of
spinal needle. Epidural needles are much larger and cranial nerves III, IV, and VI. The abducens nerve
unintentional dural puncture (UDP) may result in a (VI) is most likely affected because of its long intra-
headache of longer duration. An analysis compar- cranial course [7]. The alteration in hearing (cranial
ing the incidence of PDPH following UDP with a nerve VIII) results from the fact that the perilym-
16-gauge epidural needle to an 18-gauge epidural phatic space of the inner ear connects to the sub-
needle showed the incidence of PDPH decreased from arachnoid space through the cochlear aqueduct [8].
88 to 64% [4]. Diagnostic criteria for PDPH are as Following a dural puncture, a patent cochlear aque-
follows: duct results in a low pressure of the inner ear because
of the loss of cerebrospinal fluid (CSF) from the
(1) headache: intrathecal space. This low pressure disturbs the hair
(a) worsens within 15 min of sitting or stand- cells of the inner ear with an alteration of hearing.
ing; Patients usually complain of an inability to detect
(b) improves within 15 min after lying down; sounds in the low-frequency range.
(c) must have one of the following: The cause of headache following UDP is felt to
(i) neck stiffness; be because of the loss of CSF into the epidural space
(ii) tinnitus; through the dural rent [9]. This postulated mech-
(iii) hypacusia; and anism has been confirmed by a clinical investigation
(iv) photophobia; in which withdrawal of CSF produced the symptoms
(2) dural puncture has been performed; of a PDPH, whereas returning the fluid relieves the
(3) headache develops within 5 days after dural headache [10]. Furthermore, MRI of five patients
puncture; and with PDPH following UDP showed a large collection
(4) headache resolves: of fluid in the epidural space [11]. If the rate of CSF
(a) spontaneously within 1 week (95% of loss through the dural puncture exceeds the pro-
cases); and duction, low pressure occurs within the intrathecal
(b) within 48 h after epidural blood patch (EBP). space. This low pressure causes a loss of the cushion
effect within the cranium, causing the brain to sag
&
Webb et al. [5 ] examined the long-term out- within the cranium, pulling on the falx cerebri,
come of individuals who experienced an UDP with a cerebral blood vessels, and tentorium [12]. A second
17-gauge Tuohy needle. These 40 individuals were possible cause of the headache is distension of the
matched to 40 control patients who delivered cerebral blood vessels. With the loss of CSF, the
without an UDP. Assessments, which included a pressure within the cranium is lower without a

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 Obstetric and gynecological anesthesia

concomitant decrease in cerebral intravenous pres- PDPH after dural puncture. Two new risk factors have
sure. This pressure difference causes the intracranial been recently identified: vaginal delivery and experi-
&&
blood vessels to dilate. Cerebral hyperemia may ence of the provider [14,15 ].
contribute to the mass of the brain and to its sagging The incidence of PDPH following UDP with a
within the cranium [13]. Tuohy needle is less than expected, approximately
Whereas the increase in blood within the 60% [16]. Most practitioners would have expected a
venous system in the brain is well established, the higher incidence. The likely explanation for the
effect on cerebral blood flow is less clear. A study of disagreement between the expected and actual inci-
66 patients following diagnostic lumbar puncture dence of headache is that the obstetric anesthesio-
with a 22-gauge Quincke needle and removing logist actually cares for two different types of
10-ml CSF was conducted to assess the effect on patients: those who deliver vaginally and those
cerebral blood flow [13]. Twenty-four hours after who deliver by cesarean. The risk of developing a
the dural puncture, cerebral blood flow was assessed PDPH following UDP is different in these patient
in the supine position using transcranial Doppler. populations (Fig. 1). Thirty-three patients with a
Twenty-one of the 61 patients developed a PDPH single UDP with a 17-gauge Tuohy needle were
and had a decrease in mean velocity and peak identified [17]. Of the 33 patients, 23 of them
systolic velocity. This finding suggests that the actively pushed during the second stage of labor
arterial system is also affected by the CSF loss and and delivered vaginally, whereas 10 of them under-
undergoes dilatation. In addition, the pulsatility went cesarean delivery prior to the second stage of
index decreased (the pulsatility index reflects intra- labor. Only one patient in the cesarean delivery
cranial pressure; a decrease in the pulsatility index group developed a PDPH, this patient did not
accompanies vascular dilation). Unlike previous require an EBP. Among women who delivered vagi-
studies, the decrease in the pulsatility index corre- nally, 16 developed a PDPH; 13 of these 16 patients
lated strongly with the severity of the PDPH: the required an EBP. There was a strong correlation
greater the decline, the more severe the headache. between the length of time spent pushing and
Thus, current evidence supports the hypothesis that the development of a PDPH. The increased risk of
PDPH results from a loss of CSF and has contributions developing a PDPH following UDP during epidural
from sagging of the brain in the cranial vault, as well placement for vaginal delivery was confirmed in a
as cerebral arterial and venous dilatation to its cause. study which was actually designed to investigate the
value of a prophylactic EBP [18]. The study included
64 patients who had an UDP: 51 of the patients
Risk factors delivered vaginally, whereas 13 of the patients had
Not all patients who experience a dural puncture cesarean delivery. The percentage of patients with a
develop a headache. There are certain factors that PDPH was much higher in the vaginal delivery group
increase the risk of developing a PDPH. Younger age, (85 vs. 20%) and the percentage of patients without
female sex, cutting needle, and needle bevel direction a PDPH was higher in the cesarean delivery group
perpendicular to the longitudinal axis of the spine (80 vs. 15%). These studies suggest that bearing
have been shown to increase the risk of developing a down during the second stage may increase CSF
loss, increase the size of the dural rent, or alter the
cerebral mechanics which increases the risk of
headache.
Another recently identified risk factor for the
Percentage of 90
patients with 80
development of PDPH after UDP is the experience
headache 70 of the provider. The placement of an epidural
60 catheter is technically one of the most challenging
50 procedures and generally requires approximately
40 90 performances to achieve reasonable competence
30 [18]. Although designed to study the role of intra-
20
thecal catheter placement in the management of
10 &&
UDP, Russell [15 ] also examined the risk factors
0
Cesarean Vaginal for the development of a headache. After controlling
delivery delivery for the incidence of UDP (higher in less-experienced
providers), the authors found that as the providers’
FIGURE 1. Percentage of patients who develop a postdural experience increased, the chance of developing a
puncture headache following unintentional dural puncture. headache decreased. This finding has been confirmed
Data from [14,17]. in a study of lumbar punctures. De Almeida et al. [19]

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 Postdural puncture headache Gaiser

studied the incidence of PDPH in research volunteers the injection of autologous blood through the epi-
who participated in studies requiring lumbar punc- dural catheter prior to removing the catheter. The
ture to analyze the biomarkers in CSF. The studies technique became popular after several case series
were conducted using a 22-gauge pencil-point nee- suggested its efficacy [22]. However, the debate was
dle. If the provider performing the lumbar puncture resolved with the publication of a double-blinded
had performed two or fewer lumbar punctures prior randomized controlled trial of 64 patients who had
to the current one, the risk of developing a PDPH was UDP [16]. Half of the patients were randomized
increased (odds ratio 2.1). Possible explanations for to the prophylactic EBP, whereas the other half
the finding of an association between proceduralist received catheter sham procedure. There was no
experience and PDPH include failure to recognize difference in the incidence of PDPH, the severity
an initial dural puncture and puncturing the dura a of PDPH, or the need for EBP. Thus, there is no
second time, advancing the local anesthetic infiltra- evidence that a prophylactic EBP is helpful, and in
tion needle too far, resulting in two dural punctures, fact, it may be harmful. It is an unnecessary procedure
or a difference in handling the needle which results in in approximately 40% of patients, as not all patients
a larger dural rent. with UDP go on to develop a PDPH. Additionally, the
There has been much debate concerning the procedure requires the injection of blood through
choice of medium (air or saline) for the loss of resist- a possibly contaminated epidural catheter and
ance technique used to identify the epidural space. although not reported, may put patients at risk for
The use of air may increase the risk of headache. In a neuraxial canal infection.
study of 2975 patients who received 3730 epidural The use of epidural morphine after UDP has been
injections for chronic pain by a single proceduralist, shown to prevent PDPH [23]. A randomized double-
1812 patients had the epidural space identified by blind trial examined this use in 50 patients with UDP,
loss of resistance to air and the remaining had loss of examining two epidural injections 24 h apart of
resistance to saline [20]. There was no difference in either 3 mg morphine or saline [24]. The incidence
the incidence of dural puncture (2.2% in each group). of headache was significantly different, 48% in the
The incidence of headache was markedly different, saline group and 12% in the morphine group. No
especially in the first 24 h, 34% (air) vs. 10% (saline). patient in the epidural morphine group required an
On day 3 or later, there was no difference in the EBP in contrast to six patients (25%) in the saline
incidence of headache. The headache in the loss of group. The incidence of side-effects was higher in the
resistance to air group was not a typical PDPH, rather epidural morphine group, with 44% experiencing
it was sharp, diffuse, and nonpositional. This head- nausea and vomiting and 12% experiencing pruritus.
ache was consistent with the headache that occurs Despite the impressive results, this technique is not
with pneumoencephalography. Thus, in order to used frequently. Practitioners are concerned about
limit the headache associated with the loss of resist- the higher incidence of side-effects. Furthermore,
ance to air technique as well to limit the patchy there is the concern of respiratory depression for
blockade, the smallest amount of air possible should 24 h after the administration of epidural morphine
be used to identify the epidural space. In another as the safety of this dose of epidural morphine in the
study that examined air vs. saline for the loss of presence of a large-dural puncture has not been
resistance technique, the anesthesiologist used either established. The guidelines for the detection of respir-
air or saline based upon personal preference in 929 atory depression following neuraxial opioids recom-
parturients [21]. Choosing either medium for loss of mend that monitoring be performed for a minimum
resistance resulted in no difference in UDP or in of 24 h after administration [25]. As such, to effec-
complications between air and saline, including tively employ this maneuver, the patient must
PDPH. Thus, practitioners should remain with the remain in the hospital for 48 h after delivery.
medium with which they are most comfortable. If Another proposed means to prevent a PDPH
loss of resistance to air is the preferred method, the following UDP is the intravenous administration
amount of air used to identify the epidural space of cosyntropin [26]. Over a 3-year period, 90 patients
should be the least amount possible. experiencing UDP during epidural analgesia for
vaginal delivery were randomized to receive either
1 mg cosyntropin or saline intravenously. The
Prevention incidence of headache was significantly different
There have been several studies examining the (33% in the cosyntropin group vs. 69% in the saline
techniques to prevent a PDPH once UDP has group) and fewer patients required an EBP in the
occurred. As EBP is so effective in the treatment of cosyntropin group, 5 vs. 13. The major concern with
a PDPH, it was reasoned that a prophylactic EBP the study is the lack of explanation for the beneficial
would prevent a PDPH. A prophylactic EBP involves effect of cosyntropin. The authors postulated that

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 Obstetric and gynecological anesthesia

cosyntropin may increase the CSF production, but needle either to intrathecal catheter insertion and
this point has never been studied. Another concern- leaving it in place for at least 24 h after delivery or to
ing point was the lack of reason for the choice of resiting the epidural catheter at another interspace.
dose. The cosyntropin dose used to assess adrenal Of the 115 women, 18 were excluded because of
function is 0.25 mg. In this study, the patients complications. The insertion of an intrathecal
received four times this dose. Side-effects of cosyn- catheter did not reduce the incidence of PDPH
tropin include bradycardia, tachycardia, hyperten- (intrathecal 72% vs. epidural 62%) or the need
sion, hypersensitivity, and seizures [27]. for EBP (50 vs. 72%, respectively). This study is
extremely important in that it establishes that intra-
thecal catheter placement following UDP does not
Intrathecal catheters prevent headache.
Given that the mechanism for the development of Although the results do not support intrathecal
PDPH is a hole in the dura with subsequent loss of catheter placement for the prevention of PDPH, the
CSF, it stands to reason that any maneuver that study suggested that placement of an intrathecal
limits the loss of CSF into the epidural space would catheter may be useful for other reasons. In the
decrease the incidence or severity of headache. This repeat epidural catheter group, over one-third of
theory served as the rationale for the placement of women suffered complications, a rate three times
an intrathecal catheter following UDP. The presence greater than in the intrathecal catheter placement
&&
of the catheter through the hole should theoreti- group [15 ]. This finding suggests that in the setting
cally limit the loss of CSF as well as stimulate a of UDP, when the proceduralist may be having
fibrotic response that would result in a smaller hole. difficulty identifying the epidural space, the place-
The first authors to investigate this theory were ment of an intrathecal catheter allows the patient to
Norris and Leighton [28]. Despite the placement receive analgesia faster and does not place the
of an intrathecal catheter with immediate removal patient at risk of repeat UDP. In certain instances,
after delivery, there was no difference in the inci- it may be prudent to place an intrathecal catheter
dence of PDPH compared with patients who had an despite the theoretical risk of increased infection.
epidural catheter sited at another spinal level There is no benefit to leaving the intrathecal
immediately after the UDP. Ayad et al. [29] modified catheter in place for 24 h. It is important to remem-
the protocol by leaving the intrathecal catheter in ber that an intrathecal catheter is a connection to
place for 24 h after delivery. With this approach, the the central nervous system, which possibly increases
incidence of PDPH in this observational study was the risk of meningitis and of accidental disconnec-
6.2% in the 24-h intrathecal catheter group, 51.4% tion with loss of CSF.
in a group who had an intrathecal catheter for the
duration of labor only, and 91.9% in the control
group (epidural catheter). This study, published in Treatment
2003, had a significant impact on clinical practice Many practitioners recommend the use of intrave-
throughout the world. nous caffeine for the treatment of a PDPH. Caffeine
&&
Respondents to a survey in North America [30 ] has a vasoconstrictive effect in the cranium and
reported placing an intrathecal catheter 25% of the reduces the cerebral blood flow [35]. A review
time; if an intrathecal catheter was placed, it was left addresses the use of caffeine for this purpose. The
for 24 h by the overwhelming majority of respond- article identifies the lack of evidence for the use of
ents. This practice is similar to that in other caffeine for the treatment of PDPH [36]. The major
locations throughout the world as indicated by study that advocated for the use of intravenous
the survey responses in the UK (28% place an intra- caffeine benzoate 500 mg included 41 patients
thecal catheter) [31], in Turkey (36% place an intra- who developed a PDPH following spinal anesthesia.
thecal catheter) [32], and in Australia (35% place an The blinding and randomization were unclear in
intrathecal catheter) [33]. However, the success of this study, rendering the results suspect. This study
an intrathecal catheter and of leaving it in place for is the only one to evaluate intravenous caffeine. The
24 h was not as dramatic as that described by Ayad other study examined oral caffeine and did not find
et al. When examining their 10 years’ experience a benefit.
with UDP, van de Velde et al. [34] reported the The definitive treatment for a PDPH is an EBP,
placement of an intrathecal catheter with removal which involves the injection of autologous blood
24 h later did not reduce the incidence of PDPH. into the epidural space. The postulated mechanism
Given these conflicting results, a randomized study for its effectiveness is that it initially increases pres-
&&
was required. Russell [15 ] randomized 115 women sure in the lumbar neuraxial canal, compressing the
after UDP with a 16-gauge or 18-gauge epidural thecal sac. This increased pressure translocates CSF

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 Postdural puncture headache Gaiser

from the spinal canal to the cranium [37]. Mainten- questions these results. Two years following an
ance of the therapeutic effect is attributed to the clot EBP for an UDP, a patient had an epidurogram
preventing further CSF loss [38]. The first person to [45]. The spread of contrast material was severely
postulate that blood may act as a sealing material for restricted, extending only between T12 and L2. In
dural puncture was Gormley [39], who noted that another patient who had an epidurogram 2 years
patients with a bloody lumbar puncture had a lower following EBP, the X-ray showed contrast material
likelihood of developing a headache compared with limited to L3. These two cases suggest that an EBP
those who did not. Gormley studied six patients may result in scarring in a limited population. It
and himself. All had a PDPH which resolved with would be interesting to determine the precipitating
the injection of 2–3 ml of blood. Subsequent factors that resulted in the scarring in these patients
practitioners were unable to repeat these results, which was not seen in the case–control study.
most likely because of inadequate blood volume. The management of PDPH tends to vary by
The amount of blood required for an EBP has institution. A survey was sent to members of the
been debated since Gormley introduced the tech- Society of Obstetric Anesthesia and Perinatology to
nique. In a nonrandomized study, 300 parturients determine the approach to patients with UDP [11].
with PDPH received varying amounts of epidural Despite their proven ineffectiveness, many prac-
blood, ranging from 6 to 25 ml [40]. The risk of titioners continue to use intravenous caffeine and
having partial headache relief, defined as return of bed rest. Another worrisome response was the lack
the PDPH within 24 h, was greater if the volume was of follow-up of patients following UDP. The high
less than 30 ml. These results conflict with the percentage of claims for headache in obstetric
results of Taivainen et al. [41] who did not find patients in the ASA Closed Claims database is a
any difference in success when volumes greater than testament to the anger at the lack of follow-up
10 ml were used. Many practitioners did not agree [2]. The most concerning issue identified in the
with these relatively small volumes. Riley and survey was the lack of protocol following UDP.
Spiegel [42] reported two patients, one who received Management is left to the discretion of the provider.
a single EBP of 58 ml and another who received three Given the conflicting data and opinions, a written
EBPs for a total volume of 165 ml. One patient protocol is important and should be followed by all
developed a spinal subdural hematoma and the members of the group. The key components to a
other, arachnoiditis. These studies and case reports protocol are suggested in the list below. Suggested
render it clear that the optimal volume for an EBP components to a successful management plan for
was not known, requiring a randomized study. UDP are as follows:
In a multicenter, international study, 121
women with UDP (with 16-gauge, 17-gauge, and (1) See all patients (regardless of whether or not
18-gauge epidural needles) and PDPH were random- UDP occurred).
ized to receive an EBP with 15, 20, or 30 ml of blood (2) Track all patients with symptoms of PDPH.
&&
[43 ]. The average time from the onset of PDPH to (3) If patient had UDP (regardless of symptoms) or
EBP was 2 days. The incidence of partial relief from if the patient had symptoms of PDPH, follow
the EBP was 51, 41, and 41%, respectively, and daily until discharge. Consider making a post-
complete relief 10, 32, and 26%, respectively. If discharge telephone call.
the patient complained of severe back pain during (4) Intravenous caffeine and bed rest have no
injection, the injection was stopped. Thus, only proven benefit.
81% of participants in the 20-ml group and 54% (5) For persistence of symptoms greater than 24 h,
of participants in the 30-ml group received the discuss with the patient the risks/benefits of EBP
assigned volume. The authors concluded that the using 20 ml blood. Stop the injection of blood if
optimal volume of blood for an EBP was 20 ml. There patient complains of symptoms of back or leg
was no advantage to increasing the amount, with pain.
the larger amounts being limited because of the (6) If UDP occurs during epidural catheter place-
development of back pain during the procedure. ment:
Complications of EBP include back pain (a) difficulty with placement – consider intra-
(approximately 80%). Another concern regarding thecal catheter
EBP is its effect on subsequent epidural anesthetics. (i) an intrathecal catheter does not affect
In a retrospective study, 29 patients with PDPH and the risk of development of a PDPH;
EBP were matched with 55 patients with dural punc- and
ture and no EBP [44]. There was no difference in the (b) no difficulty with placement – consider
success of subsequent epidural anesthetics between resiting the epidural catheter or placing
the two groups. However, a recent case report the catheter intrathecally.

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 Obstetric and gynecological anesthesia

8. Pogodzinski MS, Shallop JK, Sprung J, et al. Hearing loss and cerebrospinal
CONCLUSION fluid pressure: case report and review of the literature. Ear Nose Throat J
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9. Vakharia SB, Thomas PS, Rosenbaum AE, et al. Magnetic resonance imaging
provider. Until a means to prevent UDP during of cerebrospinal fluid leak and tamponade effect of blood patch in postdural
epidural catheter placement is developed, PDPH will puncture headache. Anesth Analg 1997; 84:585–590.
10. Kunkle EC, Ray BS, Wolff HG. Experimental studies on headache: analysis of
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a PDPH following UDP. Although two studies Neurology 1993; 43:919–926.
advocate for epidural morphine and intravenous 12. Levine DN, Rapalino O. The pathophysiology of lumbar puncture headache.
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ethical questions.
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 Postdural puncture headache Gaiser

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