Headache Medicine 2021, 12(4):293-298 p-ISSN 2178-7468, e-ISSN 2763-6178

293

ASAA

DOI: 10.48208/HeadacheMed.2021.48

Headache Medicine

Opinion

It is wrong to treat pain in CSF hypotension headache (post-lumbar

puncture headache) to allow the patient to walk!

Marcelo Moraes Valença

, Matheus Salerno Sousa

, Marcelo Andrade Valença¹ ,

Déborah Emmily de Carvalho³ , Alberto Henrique Torres Trindade da Silva³ , Juliana Ramos de Andrade

Federal University of Pernambuco, Recife, Pernambuco, Brazil

Franca Municipal University Center (Uni-Facef), Franca, São Paulo, Brazil

University of Pernambuco, Recife, Pernambuco, Brazil

Marcelo Moraes Valença

mmvalenca@yahoo.com.br

Received: November 29, 2021

Accepted: December 23, 2021

A secondary headache, common in daily practice, is the post-dural puncture headache,

which is very frequent in spinal anesthesia. Some patients in the immediate postoperative

period, when he or she got out of bed, report the appearance of pain of moderate to severe

intensity that improves when he or she returns to the lying position.

1-3

Valença and coworke-

, in an experiment with fragments of human dura mater obtained from cadaver donors of

both sexes, evaluated why women are more susceptible than men to development post-dural

puncture headache (PDPH). The experiment demonstrated that the dura mater has mechanisms

that provide spontaneous occlusion of the orice caused by the entrance of the needle, even

when placed isolated and xed an acrylic apparatus simulating the human spine in the ver-

tical position, under the pressure of 40 cm H

O. This particularity observed in cadaver dura

mater varies between individuals and also between different parts of the dura mater of the

same individual. This may explain why some individuals have post-dural puncture headache

and others do not. The experimental data revealed that dura mater fragments obtained from

women leaked more uid, and the orice remained opened longer when punctured when

compared with men.

The triggering of pain during biological events that have the potential to be life-threatening

is a crucial mechanism that is often overlooked. Numerous published articles are bringing

different alternatives in an attempt to treat a postural headache that is pathognomonic of

cerebrospinal uid (CSF) hypotension (Table 1).

4-23

Even so, one of the most used drugs to

prevent and treat post-lumbar puncture headache, caffeine, had its analgesic action questioned

in a publication of notable reputation due to being insufciently supported by the available

pharmacological and clinical proofs.

From a practical point of view, it is worth remembering that normal CSF pressure is not un-

common in patients with spontaneous intracranial hypotension and, thus, the lack of a low

opening pressure does not exclude this condition.

And spontaneous intracranial hypotension

may be encountered in patients with new-onset daily persistent headache.

There are several causes of CSF hypotension,

27-36

the most frequent after the spinal anesthesia

procedure.

Edited by:

Mario Fernando Prieto Peres

Keywords:

Post-Dural Puncture Headache

Intracranial Hypotension

Blood Patch

Epidural

Headache

Treatment

294

ASAA

Valença MM, Sousa MS, Valença MA, Carvalho DE, Silva AHTT, Andrade JR

It is wrong to treat pain in CSF hypotension headache (post-lumbar puncture headache) to allow the patient to walk!

In the intracranial space, there are three compartments: CSF,

brain parenchyma, and blood. With the exception of the

brain parenchyma, which is practically inelastic, there is a

considerable variation during the cardiac cycle in the volumes

of CSF and blood. These intracranial volumes maintain an

inversely directional relationship. When there is an increase

in the intracranial volume of blood, the CSF must leave the

cavity towards the spinal dural sac to allow blood to enter

the intracranial cavity. Cerebrospinal uid leaves and enters

through the foramen magnum about 70 times per minute in

a resting individual.

Table 1. Treatment alternatives in post-dural puncture headache.

Modied sphenopalatine ganglion block

4,8

Sphenopalatine block with lidocaine spray

Intranasal lidocaine atomization

Epidural blood patch

38-53

Synacthen depot

Caffeine

14,23,24

Sumatriptan

9,20,22

Naratriptan

Aminophylline/Theophylline

Piritramid

Ergotamine

Gabapentin

Tramadol

Paracetamol

Cosyntropin

7,18,21

Tetracosactin

In a reduced volume of the CSF, in the case of stula with

loss of CSF, the pain is caused by the exit of the CSF from the

intracranial space into the spinal dural sac. In order to keep

the intracranial volume constant with the three mentioned

compartments (i.e., brain parenchyma, CSF, and blood), there

is vasodilation, mainly of the venous sinuses and large veins,

as these vessels are quite innervated, the individual feels an

intense headache when raising the head in relation to the

trunk. By the force of gravity, this position facilitates the exit

of the already reduced volume of CSF from the intracranial

cavity to the dural sac. Another explanation for postural

headache is the descent of the cerebellar tonsils through the

foramen magnum, as in the case of a secondary Chiari,

that name is correct for this diagnosis.

Cerebrospinal uid hypotension due to a reduced volume

of CSF, as in the example of a stula, can precipitate com-

plications such as bleeding in the subdural space. It is not

uncommon for chronic subdural hematomas to appear after

the patient has undergone spinal anesthesia or after a lumbar

puncture with CSF removal.

Cerebrospinal uid hypotension

may be a cause of cortical vein thrombosis.

In addition,

cerebellar hemorrhage may also be found as a manifestation

of spontaneous intracranial hypotension.

The authors, therefore, is not against the treatment of post-

-dural puncture headache or the headache associated with

cerebrospinal uid hypotension from other causes as long

as it treats the cause of cerebrospinal uid stula, as in the

example of epidural blood patch.

39-44, 57

Also, remember

that epidural blood patch is not an uncomplicated proce-

dure (e.g., arachnoiditis, seizures and respiratory distress,

pneumocephalus, intracranial subarachnoid hemorrhage,

hydrocephalus, local infection and sepsis complication, and

spinal subdural hematoma)

38, 45-51

and should be planned

and indicated when conservative measures, including rest in

the horizontal position and hydration, have failed.

12, 52, 57

most cases, the headache disappears within a week.

In the

case of prolonged horizontal decubitus, measures to prevent

deep venous thrombosis should be taken. Other forms of CSF

stula treatment have also been published.

53, 58-61

Thus, we conclude that it is wrong to treat pain in patients

with the postural headache associated with a CSF hypoten-

sion with the intention to allow the patient to walk because

it favors the occurrence of intracranial complications that

can lead to the patient's death. The pain makes the patient

remain in the horizontal decubitus and, in this way, avoids the

exit of the CSF to the spinal dural sac, causing a substantial

intracranial hemodynamic disturbance with hemorrhagic or

thrombotic repercussions.

Conflict of interest: no conict of interest to declare

Authors' contribution: MMV – writing: original draft, review

& editing, visualization, supervision; JRA – writing: review

& editing, visualization, supervision; MSS - writing: editing,

table and references; MAV, DEC, AHTTS - writing: editing,

table and references

Marcelo Moraes Valença

https://orcid.org/0000-0003-0678-3782

Matheus Salerno Sousa

https://orcid.org/0000-0002-2335-8019

Marcelo Andrade Valença

https://orcid.org/0000-0002-0824-0928

Déborah Emmily de Carvalho

https://orcid.org/0000-0002-8068-3598

295

ASAA

Valença MM, Sousa MS, Valença MA, Carvalho DE, Silva AHTT, Andrade JR

It is wrong to treat pain in CSF hypotension headache (post-lumbar puncture headache) to allow the patient to walk!

Alberto Henrique Torres Trindade da Silva

https://orcid.org/0000-0003-2356-4426

Juliana Ramos de Andrade

https://orcid.org/0000-0002-5445-8872

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