Headache after a lumbar puncture.

Headache may result from a decrease in the volume and pressure of cerebrospinal fluid (CSF) due to a lumbar puncture or as a result of cerebrospinal fluid leakage.

Removal of CSF by lumbar puncture (LP) reduces CSF volume and pressure, as in spontaneous CSF leaks (e.g. from arachnoid cysts in the spinal canal that may rupture with coughing or sneezing). Elevating the head while sitting or standing stretches the sensitive meninges at the base of the skull, causing headache. Severe headache is dependent on body position and is accompanied by neck pain, meningismus, and vomiting. The headache is relieved only by lying down.

Headache after lumbar puncture is quite common, usually developing within a few hours to a day or two after the procedure, and can be debilitating. The risk of developing headache after lumbar puncture is increased in young people with low body weight. The risk can be reduced by using small needles. The amount of CSF removed and the length of time spent lying down after lumbar puncture do not affect the frequency of headache episodes.

Headache after lumbar puncture is clinically obvious and diagnostic measures are rarely performed; other types of hypotensive headache require additional investigation with CT or MRI. MRI with gadolinium shows diffuse contrast accumulation in the dura mater and, in severe cases, a downward shift of the brain. CSF pressure is usually decreased or undetectable if the patient has been upright for some time (gravity increases CSF loss).

The first steps are to lie down, give intravenous fluids, wear an elastic abdominal bandage, and take mild analgesics and caffeine. If these measures do not relieve the headache after lumbar puncture within 24 hours, an "epidural blood patch" (injection of a few milliliters of the patient's clotted venous blood into the epidural space) may be tried. Surgical interventions for spontaneous cerebrospinal fluid leaks are rarely required.

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