Consensus Statement | Anesthesiology

Consensus Practice Guidelines on Postdural Puncture Headache

From a Multisociety, International Working Group
A Summary Report
Vishal Uppal, MBBS, MSc; Robin Russell, MBBS; Rakesh Sondekoppam, MD; Jessica Ansari, MD; Zafeer Baber, MD; Yian Chen, MD; Kathryn DelPizzo, MD;
Dan Sebastian Dîrzu, MD; Hari Kalagara, MD; Narayan R. Kissoon, MD; Peter G. Kranz, MD; Lisa Leffert, MD; Grace Lim, MD; Clara A. Lobo, MD;
Dominique Nuala Lucas, MBBS; Eleni Moka, MD; Stephen E. Rodriguez, MD; Herman Sehmbi, MD; Manuel C. Vallejo, MD; Thomas Volk, MD; Samer Narouze, MD, PhD

Abstract Key Points

Question To improve care and enhance
IMPORTANCE Postdural puncture headache (PDPH) can follow unintentional dural puncture during
patient safety, how should clinicians
epidural techniques or intentional dural puncture during neuraxial procedures, such as a lumbar
attempt to prevent, diagnose, and
puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis, and
manage postdural puncture
management of this condition is, however, currently lacking.
headache (PDPH)?

OBJECTIVE To fill the practice guidelines void and provide comprehensive information and patient- Findings In this consensus statement, a
centric recommendations for preventing, diagnosing, and managing PDPH. multidisciplinary panel of 21
collaborators outlined
EVIDENCE REVIEW With input from committee members and stakeholders of 6 participating recommendations for the prevention,
professional societies, 10 review questions that were deemed important for the prevention, identification, and management of
diagnosis, and management of PDPH were developed. A literature search for each question was PDPH. The strength and certainty of
performed in MEDLINE on March 2, 2022. Additional relevant clinical trials, systematic reviews, and evidence of various patient, procedural,
research studies published through March 2022 were also considered for practice guideline diagnostic, and management aspects
development and shared with collaborator groups. Each group submitted a structured narrative of PDPH were graded.
review along with recommendations that were rated according to the US Preventive Services Task
Meaning These practice guidelines
Force grading of evidence. Collaborators were asked to vote anonymously on each recommendation
provide a framework for individual
using 2 rounds of a modified Delphi approach.
clinicians to assess risk, confirm
diagnosis, and adopt a systematic
FINDINGS After 2 rounds of electronic voting by a 21-member multidisciplinary collaborator team,
approach to management of PDPH.
47 recommendations were generated to provide guidance on the risk factors for and the prevention,
diagnosis, and management of PDPH, along with ratings for the strength and certainty of evidence.
A 90% to 100% consensus was obtained for almost all recommendations. Several recommendations + Invited Commentary
were rated as having moderate to low certainty. Opportunities for future research were identified.
+ Supplemental content
Author affiliations and article information are
CONCLUSIONS AND RELEVANCE Results of this consensus statement suggest that current
listed at the end of this article.
approaches to the treatment and management of PDPH are not uniform due to the paucity of
evidence. The practice guidelines, however, provide a framework for individual clinicians to assess
PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management.

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Introduction
Postdural puncture headache (PDPH) is a recognized complication of unintentional dural puncture
during epidural analgesia or intentional dural puncture for spinal anesthesia or for diagnostic or
interventional neuraxial procedures. Its incidence varies widely, with rates ranging from less than 2%
to 40% depending on procedural and patient factors.1-3

Open Access. This is an open access article distributed under the terms of the CC-BY License.

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 JAMA Network Open | Anesthesiology Consensus Practice Guidelines on Postdural Puncture Headache

Postdural puncture headache is usually postural and presents within the first 5 days of
witnessed or suspected dural puncture.4 Headache is often accompanied by neck stiffness and/or
subjective hearing symptoms. Although headache may resolve within 2 weeks, its severity may
interfere with daily activities; this severity becomes especially important to postpartum patients
caring for a newborn child. Furthermore, PDPH is associated with complications, including chronic
headache, backache, cranial nerve dysfunction, subdural hematoma (SDH), and cerebral venous
sinus thrombosis (CVST).5
Despite numerous reviews on prevention and management of PDPH, most lacked structured
recommendations. The reason is that their data were inconclusive, as the studies in these reviews
were generally small and heterogeneous, often mixing preventive and therapeutic treatments. In
2013, Bradbury et al6 presented evidence on preventive modalities for PDPH. Subsequently in 2019,
Russell et al7,8 summarized evidence on conservative management and use of an epidural blood
patch (EBP) for PDPH in obstetrics. More recent studies have been added to the current body of
literature.9 Furthermore, there is a lack of practice guidelines for both perioperative and diagnostic
or interventional settings. The current multisociety practice guidelines we developed aimed to fill this
void and provide comprehensive information and patient-centric recommendations for preventing,
diagnosing, and managing PDPH.

Methods
In accordance with the Common Rule, this Consensus Statement was exempt from institutional
review board approval and informed consent because it did not involve human participants or use
identifiable data. We followed the Standards for Quality Improvement Reporting Excellence
(SQUIRE) reporting guideline.
Two of us (V.U., S.N.), the project cochairs, initially obtained approval from the American Society
of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) guidelines committee and board of
directors. Delegates from the ASRA Pain Medicine, European Society of Regional Anaesthesia and
Pain Therapy, Society for Obstetric Anesthesia and Perinatology, Obstetric Anaesthetists’
Association, American Society of Spine Radiology, and American Interventional Headache Society
were contacted by the ASRA Pain Medicine executive director and invited to contribute to the
development of the present multisociety practice guidelines (Figure). With input from the
committee members and stakeholders, the project cochairs developed 10 review questions that we
deemed important for the prevention, diagnosis, and management of PDPH. After an initial virtual
meeting, collaborators were divided into writing groups, each of which had a designated
group leader.
A health sciences librarian conducted literature searches for each question in MEDLINE ALL on
March 2, 2022. The search block for the term PDPH that was common to all searches was combined
with search blocks that were specific to each review question (eAppendix 1 in the Supplement). Only
English-language articles published after 1960 were included. Animal studies were excluded from
all searches. Results from each search were imported into separate Covidence projects for
deduplication and screening, followed by data extraction. In addition, systematic reviews on PDPH
were searched and shared with collaborators, and references were screened to ensure no essential
references were missed.
Each group submitted a structured narrative review. Key evidence points were summarized as
statements, and practice recommendations were based on the reviewed evidence.
Recommendations were evaluated according to the US Preventive Services Task Force guidelines for
grading of evidence.10 Evidence was graded as A, B, C, D, or I (Table 1), whereas the level of certainty
was rated as high, moderate, or low (Table 2).11 Statements were presented when recommendations
were not possible (eg, for patient factors) or when there was insufficient evidence to make
recommendations. Statements were assigned a certainty level without grading, whereas
recommendations were assigned both level of certainty and grading. The editing team (including

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R.R., V.U., and R.S.) reviewed submissions, which underwent multiple iterations with collaborators to
formulate an interim draft.
The interim draft was shared electronically, with a request to each collaborator to vote
anonymously on each recommendation using a modified Delphi approach.12 We used Microsoft Excel
(Microsoft Corp) for 2 rounds of electronic voting. The Delphi evaluation criteria were simplified, and
collaborators were asked to indicate whether they agreed or disagreed with or would like to abstain

Figure. Method for Consensus Guideline Development

Step 1 Step 2 Step 3 Step 4

Expert panel identification Problem definition Literature search Methods

Invitation to experts from Development of 10 clinical • Conducted by literature • Recommendations graded

stakeholder societies to join questions based on initial survey
and nominate members: and discussion:
• ASRA 1. Clinical definition
• ESRA 2. Patient factors
• SOAP 3. Procedural factors
• OAA
• ASSR 4. Prevention
• AIHS 5. Conservative management
6. Interventional management
7. Role of imaging
8. Contraindications to
epidural blood patch
9. Epidural blood patch
10. Follow-up
specialist
• Papers from 1960 onward
included (after PDPH concept
introduced in publications)
• Searched MEDLINE ALL
on March 2, 2022
• Developed separate search
strategy for each question
• Limited to English language
• Each team screened for
published systematic reviews
and references
using US Preventive Services
Task Force grading-of-evidence
guidelines (evidence grade: A,
B, C, D, or I; certainty level:
high, moderate, or low).
• Screening performed by each
team for questions 1 through
10 separately
• Platform (Covidence)
• Deduplication
• Single-reviewer screening
(title/abstract and full-text
screening)
• Data extraction

Step 5 Step 6 Step 7 Step 8

Narrative review Round 1 voting Round 2 voting Summary of findings

• Each team contributed a
narrative review
• Drafting of evidence summary
from RCTs, cohort studies,
case reports, or systematic
reviews as applicable
• Statements or recommendations
using US Preventive Services
Task Force grading-of-evidence
guideline
• Interim draft prepared and
shared with collaborators
• Modified Delphi approach
used
• Collaborators requested to
vote anonymously on each
recommendation
• Collaborators requested to
indicate agreement (agree,
disagree, or abstain)
• Mandatory comments and
reasons for decision (if
disagreed or abstained)
• Recommendations with 100% • Final draft prepared and shared
agreement accepted, and with all collaborators AIHS indicates American Interventional Headache
recommendations with <100% • Submitted for publication
Society; ASRA, American Society of Regional
agreement underwent
voting in round 2 Anesthesia and Pain Medicine; ASSR, American Society
• Statements and of Spine Radiology; ESRA, European Society of
recommendations with >75%
agreement were accepted Regional Anaesthesia and Pain Therapy; OAA,
(final draft) Obstetric Anaesthetists’ Association; PDPH, postdural
• Language of recommendations puncture headache; RCT, randomized clinical trial;
was refined with consideration
of contributors’ comments SOAP, Society for Obstetric Anesthesia and
Perinatology.

Table 1. US Preventive Services Task Force (USPSTF) Grade Definitionsa

Evidence grade Definition Suggestions for practice

A The USPSTF recommends the service. There is high Offer or provide this service.
certainty that the net benefit is substantial.
B The USPSTF recommends the service. There is high Offer or provide this service.
certainty that the net benefit is moderate, or there
is moderate certainty that the net benefit is
moderate to substantial.
C The USPSTF recommends selectively offering or Offer or provide this service for selected
providing this service to individual patients based patients depending on individual
on professional judgment and patient preferences. circumstances.
There is at least moderate certainty that the net
benefit is small.
D The USPSTF recommends against the service. There Discourage the use of this service.
is moderate or high certainty that the service has
no net benefit or that the harms outweigh the
benefits.
I The USPSTF concludes that the current evidence is Read the clinical considerations section of
insufficient to assess the balance of benefits and USPSTF Recommendation Statement. If the
harms of the service. Evidence is lacking, of poor service is offered, patients should understand
quality, or conflicting, and the balance of benefits the uncertainty about the balance of benefits
and harms cannot be determined. and harms. a
Data from USPSTF.10

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from each recommendation.13 Collaborators were also invited to provide mandatory comments and
reasons for their decision if they disagreed or abstained.
The editing team refined and clarified the statements and recommendations after the first
round of voting. Recommendations with 100% agreement were accepted, and recommendations
with less than 100% agreement were revised with consideration of collaborators’ comments. The
aim was to increase the consensus in the second round of voting. In the second round, the
statements and recommendations with a predefined agreement greater than 75% were accepted.
This threshold was used in another ASRA Pain Medicine consensus guideline.14 The subsequent draft
was shared with all of the collaborators for final approval.

Results
The results retrieved in MEDLINE for each search question are provided in eAppendix 1 in the
Supplement. After 2 rounds of anonymous voting by the 21 multidisciplinary collaborators, the
predefined consensus was greater than 75% for all statements and recommendations. Specifically,
90% to 100% consensus was obtained for almost all recommendations after the second round of
voting (eAppendix 3 in the Supplement). The final draft was approved by each collaborator, the ASRA
Pain Medicine board of directors, and the participating societies. The complete references
supporting each section are provided in eAppendix 2 in the Supplement. The full narrative synthesis
that forms the basis of these recommendations are published elsewhere.15

Definition of PDPH
According to the 2018 definition by the International Headache Society (IHS), PDPH is a headache
attributed to low cerebrospinal fluid (CSF) pressure occurring within 5 days of a lumbar puncture
caused by CSF leakage through the dural puncture.16 Headache is usually accompanied by neck
stiffness and/or subjective hearing symptoms, remitting spontaneously within 2 weeks or after
sealing of the leak with an autologous epidural lumbar patch. As such, this IHS definition requires
evidence of low pressure or CSF leakage on cerebral imaging (showing brain sagging or
pachymeningeal enhancement or extradural CSF).
This definition has several potential weaknesses. First, neither opening nor closing pressure has
been shown to differ in studies of patients with PDPH compared with controls.17,18 Second, patients
with intracranial hypertension can have PDPH.19 Third, case reports and series have shown that
PDPH may become apparent more than 5 days after dural puncture20-22 or after hospital
discharge.23,24 Fourth, the omission of the postural component is controversial. The 2013 IHS

Table 2. US Preventive Services Task Force (USPSTF) Levels of Certainty Regarding Net Benefita
Level of
certaintyb Description
High The available evidence usually includes consistent results from well-designed, well-conducted
studies in representative primary care populations. These studies assess the effects of the preventive
service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the
results of future studies.
Moderate The available evidence is sufficient to determine the effects of the preventive service on health
outcomes, but confidence in the estimate is constrained by such factors as:
• The number, size, or quality of individual studies.
• Inconsistency of findings across individual studies.
• Limited generalizability of findings to routine primary care practice.
• Lack of coherence in the chain of evidence.
a
As more information becomes available, the magnitude or direction of the observed effect could Data from USPSTF.10
change, and this change may be large enough to alter the conclusion. b
“The USPSTF defines certainty as ‘likelihood that the
Low The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient
USPSTF assessment of the net benefit of a
because of:
• The limited number or size of studies. preventive service is correct.’ The net benefit is
• Important flaws in study design or methods. defined as benefit minus harm of the preventive
• Inconsistency of findings across individual studies.
service as implemented in a general, primary care
• Gaps in the chain of evidence.
• Findings not generalizable to routine primary care practice. population. The USPSTF assigns a certainty level
• Lack of information on important health outcomes. based on the nature of the overall evidence available
More information may allow estimation of effects on health outcomes.
to assess the net benefit of a preventive service.”10

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definition contained a postural component25: “a headache that worsens within 15 minutes after
sitting or standing and improves within 15 minutes after lying down after dural puncture has occurred
or is suspected.” An analysis of the electronic records of 27 064 parturient individuals with a
neuraxial procedure over a 10-year period found that only 8 of 142 parturient individuals with PDPH
had no postural component.4 Fifth, dural puncture may not be noticed during the procedure.26 Sixth,
an increasing body of evidence suggests that headache can persist for longer than 2 weeks.27-31

Clinical Features of PDPH

In 2021, the American Society of Anesthesiologists released a statement that based the diagnosis of
PDPH on both the clinical presentation and a detailed history and physical examination.32 Typical
symptoms included neck stiffness; pain in the cervical, thoracic, or lumbar vertebral area; subjective
hearing symptoms; visual disturbances; and vertigo. Headaches were frequently reported after
childbirth, but only some headaches may be attributed to PDPH.33
The collaborators generated 37 statements and 47 recommendations after extensively
reviewing the current evidence on PDPH. The 10 review questions we developed initially are
presented as follows along with final statements and recommendations from the collaborators'
working groups.

Question 1: When Should PDPH Be Suspected?

The statement for this question was, PDPH should be suspected if headache or neurological
symptoms, which may be relieved when lying flat, occur within 5 days of a neuraxial procedure (level
of certainty: moderate). The recommendation was as follows: inpatients who have received a
neuraxial procedure should be reviewed and evaluated for symptoms of PDPH. Outpatients should
be instructed to report symptoms of PDPH to their physicians (evidence grade: A; level of certainty:
high). Important supporting references were the Headache Classification Committee of the IHS16
and the American Society of Anesthesiologists.32

Question 2: What Patient Factors Are Associated With the Incidence of PDPH?
All statements regarding patient factors are provided in Table 3.34,35 In the statements, younger
adults and female sex were associated with an increased risk of PDPH (level of certainty: high).

Question 3: What Procedural Characteristics Are Associated With PDPH?

Statements regarding procedural factors36-38 are provided in Table 4. There were 4
recommendations for this question. First, routine use of noncutting spinal needles for lumbar
puncture for all populations is recommended (evidence grade: A; level of certainty: high). Second, if

Table 3. Patient Factors Associated With Incidence of PDPH

Level of
Factor Statement certainty
Age The preponderance of evidence suggests that in the adult population, younger High
age may be associated with an increased risk of PDPH.
Sex The preponderance of evidence suggests that female sex is associated with an High
increased risk of PDPH.
BMI Evidence does not suggest that BMI has a consistent association with an Moderate
increased risk of PDPH.
Comorbidities
Headache The preponderance of evidence suggests that a history of headaches (chronic, Moderate
contemporaneous, or prior PDPH) may be associated with an increased risk of
PDPH. The association with migraine specifically is less clear.
Smoking Limited evidence suggests that cigarette smoking might be associated with a Low
decreased risk of PDPH.
Depression There is insufficient evidence to conclude that depression is a risk for PDPH. Low
Obstetric Evidence is conflicting regarding the association between PDPH and active Low
pushing during the second stage of labor following dural puncture with an Abbreviations: BMI, body mass index; PDPH, postdural
epidural needle. puncture headache.

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using a cutting needle for lumbar puncture, the use of a narrower-gauge needle is recommended to
reduce the risk of PDPH (evidence grade: A; level of certainty: high).
Third, limited evidence supports the use of narrower-gauge noncutting needles over larger
needles for lumbar puncture to reduce the risk of PDPH (evidence grade: C; level of certainty:
moderate). Fourth, if using a cutting needle for lumbar puncture, insertion with the bevel parallel to
the long axis of the spine is preferred as it may reduce the risk of PDPH (evidence grade: B; level of
certainty: moderate).

Question 4: What Measures May Be Used to Prevent PDPH?

There were 3 statements for this question. First, after inadvertent dural puncture during attempted
epidural catheter insertion, evidence was insufficient to confirm that placement of an intrathecal
catheter decreased the risk of PDPH and EBP (level of certainty: low). Second, prophylactic EBPs via
an existing epidural catheter or as a stand-alone procedure have been performed following
inadvertent dural punctures in both obstetric and non-obstetric populations with variable success.
Not every patient who experiences a dural puncture develops a PDPH. Therefore, a policy of routine
prophylactic blood patching exposes some patients to unnecessary potential risks. Third, evidence
of a reduction in severity of PDPH with prophylactic bed rest was inconclusive (level of certainty:
moderate).
There were 5 recommendations for this question. First, after inadvertent dural puncture during
epidural catheter placement, an intrathecal catheter may be considered to provide anesthesia or
analgesia. This decision must consider the potential risks associated with intrathecal catheters
(evidence grade: C; level of certainty: low). Second, a prophylactic EBP is not recommended as
routine because there is insufficient evidence to support its effectiveness in preventing PDPH
(evidence grade: I; level of certainty: low). Third, bed rest is not routinely recommended as
prophylaxis against PDPH (evidence grade: D; level of certainty: moderate). Fourth, routine injection
of any substance intrathecally or epidurally to prevent PDPH is not recommended (evidence grade:
I; level of certainty: low). Fifth, there is insufficient evidence to recommend routine systemic drug
administration for PDPH prophylaxis (evidence grade: I; level of certainty: low). Important supporting
references were Bradbury et al,6 Heesen et al,39 and Boonmak and Boonmak.40

Question 5: What Conservative Measures May Be Used to Treat PDPH?

There were 7 recommendations for this question. First, evidence does not support the routine use of
bed rest to treat PDPH, although it may be used as a temporizing measure for symptomatic relief

Table 4. Procedural Characteristics Associated With PDPH

Level of
Factor Statement certainty
Needle type Compared with cutting needles, noncutting spinal needles are associated High
with decreased PDPH risk.
There is limited evidence regarding a particular design of noncutting spinal Low
needle and the risk of PDPH.
Needle size When using cutting needles, narrower-gauge needles reduce the risk of High
PDPH.
For noncutting needles, limited evidence suggests narrower-gauge needles Moderate
reduce the risk of PDPH.
Needle advancement Evidence is insufficient to confirm benefit of any technique used to identify Low
the epidural space on reduction of the incidence of PDPH.
No. of attempts Evidence suggests an association between the number of attempts and the Moderate
risk of PDPH.
Operator experience Evidence suggests that a higher level of operator experience level reduces Moderate
the incidence of PDPH, but the net benefit may be small.
Level of neuraxial block Evidence does not suggest an association of PDPH with the level of Moderate
epidural insertion.
Patient position Evidence suggests a lower risk of PDPH with techniques performed with Moderate
the patient in the lateral decubitus position.
Traumatic vs atraumatic Evidence suggests that the choice of needle for LP does not alter the risk of Moderate Abbreviations: LP, lumbar puncture; PDPH, postdural
tap traumatic tap and the risk of PDPH.
puncture headache.

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(evidence grade: C; level of certainty: low). Second, adequate hydration should be maintained with
oral fluids; intravenous fluid should be used when oral hydration cannot be maintained (evidence
grade: C; level of certainty: low). Third, evidence does not support the routine use of abdominal
binders or aromatherapy to treat PDPH (evidence grade: D; level of certainty: low).
Fourth, regular multimodal analgesia, including acetaminophen and nonsteroidal anti-
inflammatory drugs, should be offered to all patients with PDPH unless contraindicated41 (evidence
grade: B; level of certainty: low). Fifth, short-term use of opioids may be considered in the treatment
of PDPH if regular multimodal analgesia is ineffective (evidence grade C; level of certainty: low);
long-term opioid use is not recommended in the treatment of PDPH (evidence grade: D; level of
certainty: moderate).
Sixth, caffeine may be offered in the first 24 hours of symptoms with a maximum dose of 900
mg per day (200-300 mg if breastfeeding) and avoiding multiple sources to prevent adverse effects
(evidence grade: B; level of certainty: low). Seventh, evidence does not support the routine use of
hydrocortisone, theophylline, triptans, adrenocorticotropic hormone or cosyntropin, neostigmine or
atropine, piritramide, methergine, and gabapentin in the management of PDPH (evidence grade: I;
level of certainty: low). Important supporting references were Russell et al7 and Basurto Ona et al.42

Question 6: What Procedural Interventions May Be Used to Treat PDPH?

There were 3 statements for this question. First, the efficacy of greater occipital nerve block for
PDPH after dural puncture with wider-gauge needles was unclear (level of certainty: low). Second,
epidural saline may be of temporary benefit but should not be expected to provide long-lasting relief
of PDPH (level of certainty: low). Third, the use of fibrin glue in the treatment of PDPH has been
associated with anaphylaxis and aseptic meningitis, although it was not possible to quantify risk
(level of certainty: low).
There were 7 recommendations for this question. First, evidence does not support routine use
of acupuncture to treat PDPH (evidence grade: I; level of certainty: low). Second, evidence does not
support routine use of sphenopalatine ganglion blocks to treat PDPH (evidence grade: I; level of
certainty: low). Third, greater occipital nerve blocks may be offered to patients with PDPH after
spinal anesthesia with a narrower-gauge (ⱕ22 G) needle, although headache may recur in a
substantial proportion of patients, with more severe headache requiring an EBP (evidence grade: C;
level of certainty: moderate). Fourth, evidence does not support the use of spinal and epidural
morphine to treat PDPH (evidence grade: D; level of certainty: low). Fifth, evidence does not support
routine use of epidural dextran, gelatin, or hydroxyethyl starch to treat PDPH (evidence grade: I; level
of certainty: low). Sixth, evidence does not support routine use of fibrin glue to treat PDPH (evidence
grade: I; level of certainty: low). Seventh, fibrin glue should be reserved for management of PDPH
refractory to EBP or when autologous blood injection is contraindicated (evidence grade: I; level of
certainty: low). Important supporting references were Russell et al,8 Melchart et al,43 Sluder,44
Giaccari et al,45 and Chang et al.46

Question 7: Is Imaging Required in PDPH Management?

The statement for this question was that evidence was insufficient to assess the risk-benefit balance
for routine cranial imaging before EBP for PDPH (level of certainty: low). There were 2
recommendations for this question. First, brain imaging may be considered when nonorthostatic
headache is present or develops after initial orthostatic headache or when headache onset is more
than 5 days after suspected dural puncture (evidence grade: C; level of certainty: low). Second, focal
neurological deficits, visual changes, alterations in consciousness, or seizures, especially in the
postpartum period, should prompt neuroimaging to evaluate alternative diagnoses (evidence grade:
B; level of certainty: moderate). Important supporting references were Lee et al47 and Chambers
et al.48

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Question 8: What Are the Contraindications to an EBP?

This question had 2 statements. First, the risk of epidural hematoma was low when performing
neuraxial procedures in pregnant patients with a platelet count of 70 000 × 106 per liter or greater
providing there was no defect in platelet function or other abnormality of coagulation (level of
certainty: moderate). Second, there was insufficient evidence for recommending prophylactic
antibiotics before EBP (level of certainty: low).
There were 2 recommendations for this question. First, clinicians should follow appropriate
guidelines regarding neuraxial injection in patients receiving antithrombotics or patients with low
platelet counts (evidence grade: B; level of certainty: moderate). Second, caution should be
exercised when considering an EBP in febrile patients or patients presenting with other systemic
signs of infection. Deferring the procedure may be appropriate if there is risk of hematogenous
infection (evidence grade: C; level of certainty: moderate). Important supporting references were
Narouze et al49 and Bauer et al.50

Question 9: When and How Should an EBP Be Performed?

This question had 6 statements. First, high success rates for EBP that were reported in early studies
have not been reproduced in more recent publications, including complete headache remission
varying between 33% and 91% (level of certainty: low). Second, optimal EBP volume was unknown
and likely varied among patients due to patient factors such as size, age, degree of spondylotic spine
changes, and relative size of the dural hole (level of certainty: low). Third, despite the lack of
association between EBP volume and success rates, the most recommended volumes were between
15 and 20 mL of blood (level of certainty: low). Fourth, injection of more than 30 mL of blood did not
appear to increase the success of EBP (level of certainty: moderate). Fifth, ultrasonography-assisted
EBP had the utility for landmark clarification before EBP or for imaging guidance in patients who were
unable to receive fluoroscopy or computed tomography (level of certainty: low). Sixth, there was
insufficient evidence to recommend a specific duration of immobilization after EBP (level of
certainty: low).
There were 14 recommendations for this question. First, when PDPH is refractory to
conservative therapy and impairs activities of daily living, an EBP should be considered to treat
headache and other neurological sequelae of intracranial hypotension (evidence grade: B; level of
certainty: moderate). Second, in patients with PDPH with severe neurological symptoms (eg, hearing
loss and cranial neuropathies), EBP should be considered as a therapeutic option (evidence grade:
C; level of certainty: moderate). Third, if an EBP is performed within 48 hours of dural puncture,
patients should be counseled about a more likely need for repeat EBP to achieve symptom resolution
(evidence grade: B; level of certainty: moderate). Fourth, until symptom resolution, regular patient
follow-up should be undertaken to determine the need for repeat EBP in cases suggestive of
persistent or severe CSF leak (evidence grade: C; level of certainty: low).
Fifth, when the site of dural puncture is known, an EBP should be performed ideally at or 1 space
below this level (evidence grade: B; level of certainty: moderate). Sixth, the transforaminal approach
to the epidural space with radiologic guidance can be considered in cases of prior laminectomy near
the site of dural puncture or after unsuccessful interlaminar EBP (evidence grade: C; level of
certainty: moderate). Seventh, the decision to perform EBP under radiologic guidance should be
individualized on the basis of patient factors, including age, body mass index, degree of spondylotic
change, context of dural puncture, and prior lumbar spine surgery as well as clinician expertise
(evidence grade: I; level of certainty: low). Eighth, radiologic guidance should consider risk-benefit
analysis, available resources, follow-up capabilities, and where the clinician determines that EBP
cannot be safely performed with landmarks alone (evidence grade: I; level of certainty: low). Ninth,
strict aseptic technique should be observed in both collection and injection of autologous blood
(evidence grade: B; level of certainty: moderate). Tenth, evidence does not support the routine use
of blood cultures before an EBP (evidence grade: D; level of certainty: low).

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Eleventh, informed consent for an EBP should include the potential for repeat dural puncture,
backache, and neurological complications (evidence grade: A; level of certainty: high). Twelfth, to
minimize complications, blood should be injected slowly and incrementally. If the patient develops
substantial backache or headache (eg, pressure paresthesia), injection of blood should be stopped
and resumed based on clinical judgment when symptoms resolve (evidence grade: B; level of
certainty: moderate). Thirteenth, after an EBP, if backache persists, increases in severity, or changes
in nature, other diagnoses should be investigated (evidence grade: C; level of certainty: low).
Fourteenth, epidural analgesia and anesthesia can be effective in patients with a history of EBP and
should not be withheld (evidence grade: C; level of certainty: low). Important supporting references
were Russell et al8 and Boonmak and Boonmak.40

Question 10: What Are the Long-Term Complications of PDPH, and How Should Patients Be
Followed Up?
Statements for this question were as follows. First, evidence showed an association between
inadvertent dural puncture and/or PDPH with chronic headache, backache, neckache, depression,
cranial nerve palsy, SDH, or CVST (level of certainty: moderate). Second, evidence was insufficient to
determine whether EBP mitigates, prevents, or treats these sequelae (level of certainty: low). Third,
PDPH was associated with the development of chronic headache (level of certainty: moderate).
There were 5 recommendations for this question. First, before discharge, information regarding
PDPH sequelae should be conveyed to patients, with arrangements for appropriate follow-up and
contact information of their anesthesiologist and other health care practitioners (evidence grade: B;
level of certainty: moderate). Second, the clinician (or team member) responsible for dural puncture
leading to PDPH should ensure that other specialties or primary care physicians are informed of
PDPH management and the potential for long-term symptoms (evidence grade: B; level of certainty:
moderate).
Third, follow-up with patients who experience PDPH should be continued until headache
resolves (evidence grade: B; level of certainty: moderate). Fourth, after discharge from the hospital,
follow-up may be continued by the primary care physician. Information regarding PDPH diagnosis
and/or inadvertent dural puncture should be communicated to the primary care physician and other
specialists, with referrals to a pain or neurology specialist if indicated (evidence grade: C; level of
certainty: low). Fifth, urgent neuroimaging and referral to an appropriate specialist should be
performed for any patient with PDPH who has worsening symptoms despite an EBP, new focal
neurologic symptoms, or a change in the nature of headache (evidence grade: B; level of certainty:
moderate). Important supporting references were Mims et al51 and Barad et al.52

Discussion
The current practice guidelines we developed provide structured and evidence-based
recommendations on pertinent aspects of PDPH, including risk factors, diagnosis, preventive and
prophylactic measures, and therapeutic options and their adverse effects. These systematic and
evidence-based practice guidelines for PDPH diagnosis and management may reduce morbidity and
mortality in patients with PDPH. In addition, they may reduce the economic implications for the
health care system and society. The diagnostic criteria for PDPH have changed with subsequent
iterations of the IHS guidelines,16 and while the understanding of the pathophysiological processes
and clinical course of PDPH continues to evolve, diagnostic criteria may again change over time.
A crucial aspect of these practice guidelines is identifying risk factors before performing an
intentional dural puncture or a procedure that carries the potential risk of unintentional dural
puncture to mitigate the risks. The clinician should assess the procedure’s risk-benefit profile and
consider whether dural puncture is justifiable. Salient risk factors delineated in these practice
guidelines that showed a high level of certainty, such as needle size, type of needle, and patient
factors (younger age and female sex), need to be considered before offering neuraxial procedures.

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Another vital aspect of these practice guidelines is incorporating an informed consent process
for the possibility of PDPH before performing neuraxial procedures. Any center offering lumbar
puncture or neuraxial procedures should have a policy on postdischarge follow-up of patients. The
policy should include (1) inpatient and outpatient services for identifying and managing PDPH, (2) a
plan to diagnose and manage PDPH until resolution, and (3) a pathway to access care to identify and
prevent complications of PDPH. Because symptoms of PDPH are similar to other causes of headache,
including those associated with intracranial hypertension (such as SDH and CVST), a high index of
suspicion should exist when typical features of PDPH are not present or when therapies for PDPH
remain ineffective.

Limitations
There were multiple challenges to developing evidence-based practice guidelines for PDPH,
including the wide variety of practice conditions and heterogeneity of the patient population. The
evidence review we conducted focused on adult patients, with most of the evidence emanating from
publications on anesthesia and lacks patient representation. The review may not have encompassed
all clinical scenarios (eg, diagnostic dural punctures, intrathecal chemotherapy, and chronic pain
interventions) or special populations (eg, pediatric population or patients with multiple
comorbidities). Future studies on the effectiveness of diagnostic and therapeutic options and the
prevention of serious complications of PDPH are needed. Investigators may consider novel study
methods, such as registry trials and adaptive study designs, as conventional study methods (eg,
randomized clinical trials) may be impractical due to low event rates.
Despite advances in evaluation and management of PDPH in the past decades, several
recommendations remained of moderate to low certainty because of the source studies’ small
sample size, suboptimal design, or, at times, out-of-date evidence. A prime example was the frequent
use of caffeine in the management of PDPH, which was based on limited evidence from 2 small
randomized clinical trials.53,54 However, excessive caffeine administration may be associated with
adverse effects, such as withdrawal, dehydration, and even seizures. Similarly, 4 randomized clinical
trials55-58 investigated ideal timing for EBP. Their results were conflicting, but overall, there is
opportunity for additional trials to improve the evidence on this topic. In obstetric settings, most
observational studies suggested that EBP failure (defined as requiring more than 1 EBP) was more
likely when EBP was performed within 24 to 48 hours of dural puncture.8 Data from observational
studies may have selection bias. In patients with severe headaches within 24 hours of the puncture,
the dural hole may be large enough to cause a severe CSF leak that requires further intervention (ie,
repeat EBP).
Another reason for the moderate to low certainty of evidence was emerging therapies, notably
the procedural options for PDPH management. Several interventional techniques, such as greater
occipital nerve block or sphenopalatine ganglion blocks, are novel therapies that need more robust
evidence. A similar scenario exists with optimal imaging guidance for performance of a blood patch
(fluoroscopic guidance vs landmark approach). Furthermore, with the availability of better evidence,
our confidence in the certainty of evidence for these recommendations may change.

Conclusions
This consensus statement found that current approaches to the treatment and management of
PDPH were not uniform and were hindered by the paucity of evidence. The practice guidelines we
developed provide a framework for individual clinicians to assess PDPH risk, confirm the diagnosis,
and adopt a systematic approach to its management.

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ARTICLE INFORMATION
Accepted for Publication: June 1, 2023.
Published: August 15, 2023. doi:10.1001/jamanetworkopen.2023.25387
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Uppal V
et al. JAMA Network Open.
Corresponding Author: Vishal Uppal, MBBS, MSc, Department of Anesthesia, Perioperative Medicine and Pain
Management, Dalhousie University, 1276 South Park St, 10W Victoria, Halifax, NS B3H 2Y9, Canada
(v.uppal@dal.ca).
Author Affiliations: Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie
University, Halifax, Nova Scotia, Canada (Uppal); Nuffield Department of Anaesthetics, Oxford University Hospitals
National Health Service (NHS) Foundation Trust, Oxford, England (Russell); Department of Anesthesia, University
of Iowa Carver College of Medicine, Iowa City (Sondekoppam); Anesthesia Department, Stanford Health Care,
Stanford, California (Ansari); Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley
Hospital, Tufts University School of Medicine, Boston, Massachusetts (Baber); Department of Anesthesiology,
Perioperative and Pain Medicine, Stanford University, Stanford, California (Chen); Department of Anesthesiology,
Critical Care and Pain Management, Hospital for Special Surgery, New York, New York (DelPizzo); Department of
Anaesthesia and Intensive Care, Emergency County Hospital, Cluj-Napoca, Romania (Dîrzu); Department of
Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida (Kalagara); Department of
Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota (Kissoon); Department of
Radiology, Duke University Medical Center, Durham, North Carolina (Kranz); Yale University School of Medicine,
Yale New Haven Hospital and Bridgeport Hospital, New Haven, Connecticut (Leffert); Department of
Anesthesiology and Perioperative Medicine, Department of Obstetrics and Gynecology, University of Pittsburgh
School of Medicine, University of Pittsburgh Medical Center Magee Hospital, Pittsburgh, Pennsylvania (Lim);
Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, United
Arab Emirates (Lobo); Department of Anaesthesia, London Northwest University Healthcare NHS Trust, London,
England (Lucas); Anaesthesiology Department, Creta Interclinic Hospital–Hellenic Healthcare Group, Heraklion,
Crete, Greece (Moka); Walter Reed National Military Medical Center, Bethesda, Maryland (Rodriguez); Department
of Anesthesia, University of Western Ontario, London, Ontario, Canada (Sehmbi); Medical Education,
Anesthesiology, Obstetrics and Gynecology, West Virginia University, Morgantown (Vallejo); Department of
Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University
Faculty of Medicine, Saarbrücken, Germany (Volk); Rootstown and Center for Pain Medicine, Western Reserve
Hospital, Cuyahoga Falls, Ohio (Narouze).
Author Contributions: Drs Uppal and Russell had full access to all of the data in the study and take responsibility
for the integrity of the data and the accuracy of the data analysis.
Concept and design: Uppal, Sondekoppam, Ansari, Baber, Chen, Dîrzu, Kalagara, Kissoon, Leffert, Lim, Lucas,
Moka, Sehmbi, Vallejo, Volk, Narouze.
Acquisition, analysis, or interpretation of data: Uppal, Russell, Sondekoppam, Ansari, Baber, Chen, DelPizzo, Dîrzu,
Kissoon, Kranz, Leffert, Lim, Lobo, Lucas, Moka, Rodriguez, Sehmbi, Vallejo, Volk, Narouze.
Drafting of the manuscript: Uppal, Russell, Baber, Chen, DelPizzo, Dîrzu, Kalagara, Kissoon, Kranz, Leffert, Lim,
Lobo, Lucas, Moka, Rodriguez, Sehmbi, Vallejo, Volk, Narouze.
Critical review of the manuscript for important intellectual content: Uppal, Russell, Sondekoppam, Ansari, Baber,
Chen, DelPizzo, Dîrzu, Kalagara, Kissoon, Kranz, Leffert, Lim, Lobo, Lucas, Rodriguez, Vallejo, Volk, Narouze.
Administrative, technical, or material support: Uppal, Sondekoppam, Baber, Chen, Dîrzu, Kissoon, Leffert, Lim,
Lobo, Lucas, Sehmbi, Vallejo, Narouze.
Supervision: Narouze.
Conflict of Interest Disclosures: Dr Uppal reported being the associate editor of the Canadian Journal of
Anesthesia. Dr Sondekoppam reported receiving personal fees from CIVCO Medical Instruments Co outside the
submitted work. Dr Kissoon reported receiving grants from Nevro, royalties from UpToDate, and consulting fees
from Bright Minds Biosciences outside the submitted work. Dr Lim reported receiving salary support from the
National Institutes of Health Office of Research on Women’s Health, consulting fees from Octapharma, Heron
Pharmaceuticals, and for medical expert testimony; grants from Edwards Lifesciences, and royalties from
Cambridge University Press outside the submitted work. Dr Volk reported receiving lecture fees from B. Braun
Medical and Pajunk outside the submitted work. No other disclosures were reported.
Additional Contributions: Angela Stengel, MS, CAE, American Society of Regional Anesthesia and Pain Medicine,
provided project coordination, and Kristy Hancock, MLIS, Maritime Strategy for Patient-Oriented Research
Support for People and Patient-Oriented Research and Trials Unit Research Services, assisted with the literature
search. These individuals received no additional compensation, outside of their usual salary, for their

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 JAMA Network Open | Anesthesiology Consensus Practice Guidelines on Postdural Puncture Headache

contributions. The Department of Anesthesia at the Perioperative Medicine and Pain Management of Dalhousie
University provided the open access fee for this publication. Editorial assistance from Nascent Medical LLC was
funded by ASRA Pain Medicine.

REFERENCES
1. Flaatten H, Rodt S, Rosland J, Vamnes J. Postoperative headache in young patients after spinal anaesthesia.
Anaesthesia. 1987;42(2):202-205. doi:10.1111/j.1365-2044.1987.tb03001.x
2. Flaatten H, Rodt SA, Vamnes J, Rosland J, Wisborg T, Koller ME. Postdural puncture headache: a comparison
between 26- and 29-gauge needles in young patients. Anaesthesia. 1989;44(2):147-149. doi:10.1111/j.1365-2044.
1989.tb11167.x
3. Frumin MJ. Spinal anesthesia using a 32-gauge needle. Anesthesiology. 1969;30(6):599-603. doi:10.1097/
00000542-196906000-00004
4. Loures V, Savoldelli G, Kern K, Haller G. Atypical headache following dural puncture in obstetrics. Int J Obstet
Anesth. 2014;23(3):246-252. doi:10.1016/j.ijoa.2014.04.005
5. Sachs A, Smiley R. Post-dural puncture headache: the worst common complication in obstetric anesthesia.
Semin Perinatol. 2014;38(6):386-394. doi:10.1053/j.semperi.2014.07.007
6. Bradbury CL, Singh SI, Badder SR, Wakely LJ, Jones PM. Prevention of post-dural puncture headache in
parturients: a systematic review and meta-analysis. Acta Anaesthesiol Scand. 2013;57(4):417-430. doi:10.1111/
aas.12047
7. Russell R, Laxton C, Lucas DN, Niewiarowski J, Scrutton M, Stocks G. Treatment of obstetric post-dural puncture
headache: part 1—conservative and pharmacological management. Int J Obstet Anesth. 2019;38:93-103. doi:10.
1016/j.ijoa.2018.12.006
8. Russell R, Laxton C, Lucas DN, Niewiarowski J, Scrutton M, Stocks G. Treatment of obstetric post-dural puncture
headache. Part 2: epidural blood patch. Int J Obstet Anesth. 2019;38:104-118. doi:10.1016/j.ijoa.2018.12.005
9. Jespersen MS, Jaeger P, Ægidius KL, et al. Sphenopalatine ganglion block for the treatment of postdural
puncture headache: a randomised, blinded, clinical trial. Br J Anaesth. 2020;124(6):739-747. doi:10.1016/j.bja.
2020.02.025
10. US Preventive Services Task Force. Grade definitions after July 2012. Accessed November 20, 2022. https://
www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/grade-definitions#july2012
11. Cohen SP, Bhaskar A, Bhatia A, et al. Consensus practice guidelines on interventions for lumbar facet joint pain
from a multispecialty, international working group. Reg Anesth Pain Med. 2020;45(6):424-467. doi:10.1136/rapm-
2019-101243
12. Diamond IR, Grant RC, Feldman BM, et al. Defining consensus: a systematic review recommends methodologic
criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67(4):401-409. doi:10.1016/j.jclinepi.2013.12.002
13. Taylor E. We agree, don’t we? the Delphi method for health environments research. HERD. 2020;13(1):11-23.
doi:10.1177/1937586719887709
14. Shah S, Schwenk ES, Sondekoppam RV, et al. ASRA Pain Medicine consensus guidelines on the management
of the perioperative patient on cannabis and cannabinoids. Reg Anesth Pain Med. 2023;48(3):97-117. doi:10.1136/
rapm-2022-104013
15. Uppal V, Russell R, Sondekoppam RV, et al. Evidence-based clinical practice guidelines on postdural puncture
headache: a consensus report from a Multisociety International Working Group. Reg Anesth Pain Med. Published
online August 15, 2023 doi:10.1136/rapm-2023-104817
16. Headache Classification Committee of the International Headache Society (IHS). The International
Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211. doi:10.1177/0333102417738202
17. Smith EA, Thorburn J, Duckworth RA, Reid JA. A comparison of 25 G and 27 G Whitacre needles for caesarean
section. Anaesthesia. 1994;49(10):859-862. doi:10.1111/j.1365-2044.1994.tb04258.x
18. Wang YF, Fuh JL, Lirng JF, et al. Cerebrospinal fluid leakage and headache after lumbar puncture: a prospective
non-invasive imaging study. Brain. 2015;138(pt 6):1492-1498. doi:10.1093/brain/awv016
19. Didier-Laurent A, De Gaalon S, Ferhat S, et al. Does post dural puncture headache exist in idiopathic
intracranial hypertension? a pilot study. Rev Neurol (Paris). 2021;177(6):676-682. doi:10.1016/j.neurol.2020.
06.017
20. Amorim JA, Gomes de Barros MV, Valença MM. Post-dural (post-lumbar) puncture headache: risk factors and
clinical features. Cephalalgia. 2012;32(12):916-923. doi:10.1177/0333102412453951

JAMA Network Open. 2023;6(8):e2325387. doi:10.1001/jamanetworkopen.2023.25387 (Reprinted) August 15, 2023 12/14

Downloaded from jamanetwork.com by guest on 03/23/2024

 JAMA Network Open | Anesthesiology Consensus Practice Guidelines on Postdural Puncture Headache

21. Lybecker H, Djernes M, Schmidt JF. Postdural puncture headache (PDPH): onset, duration, severity, and
associated symptoms: an analysis of 75 consecutive patients with PDPH. Acta Anaesthesiol Scand. 1995;39(5):
605-612. doi:10.1111/j.1399-6576.1995.tb04135.x
22. Vilming ST, Kloster R. The time course of post-lumbar puncture headache. Cephalalgia. 1998;18(2):97-100.
doi:10.1046/j.1468-2982.1998.1802097.x
23. Hayes NE, Wheelahan JM, Ross A. Self-reported post-discharge symptoms following obstetric neuraxial
blockade. Int J Obstet Anesth. 2010;19(4):405-409. doi:10.1016/j.ijoa.2010.04.004
24. Moore AR, Wieczorek PM, Carvalho JCA. Association between post-dural puncture headache after neuraxial
anesthesia in childbirth and intracranial subdural hematoma. JAMA Neurol. 2020;77(1):65-72. doi:10.1001/
jamaneurol.2019.2995
25. Headache Classification Committee of the International Headache Society (IHS). The International
Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808. doi:10.1177/
0333102413485658
26. Sprigge JS, Harper SJ. Accidental dural puncture and post dural puncture headache in obstetric anaesthesia:
presentation and management: a 23-year survey in a district general hospital. Anaesthesia. 2008;63(1):36-43.
doi:10.1111/j.1365-2044.2007.05285.x
27. MacArthur C, Lewis M, Knox EG. Accidental dural puncture in obstetric patients and long term symptoms.
BMJ. 1993;306(6882):883-885. doi:10.1136/bmj.306.6882.883
28. Webb CA, Weyker PD, Zhang L, et al. Unintentional dural puncture with a Tuohy needle increases risk of
chronic headache. Anesth Analg. 2012;115(1):124-132. doi:10.1213/ANE.0b013e3182501c06
29. Ranganathan P, Golfeiz C, Phelps AL, et al. Chronic headache and backache are long-term sequelae of
unintentional dural puncture in the obstetric population. J Clin Anesth. 2015;27(3):201-206. doi:10.1016/j.jclinane.
2014.07.008
30. Guglielminotti J, Landau R, Li G. Major neurologic complications associated with postdural puncture headache
in obstetrics: a retrospective cohort study. Anesth Analg. 2019;129(5):1328-1336. doi:10.1213/ANE.
0000000000004336
31. Niraj G, Mushambi M, Gauthama P, et al; Accidental Dural Puncture Outcome Study Collaborative Group.
Persistent headache and low back pain after accidental dural puncture in the obstetric population: a prospective,
observational, multicentre cohort study. Anaesthesia. 2021;76(8):1068-1076. doi:10.1111/anae.15491
32. American Society of Anesthesiologists. Statement on post-dural puncture headache management. Accessed
August 4, 2022. https://www.asahq.org/standards-and-guidelines/statement-on-post-dural-puncture-headache-
management
33. Goldszmidt E, Kern R, Chaput A, Macarthur A. The incidence and etiology of postpartum headaches:
a prospective cohort study. Can J Anaesth. 2005;52(9):971-977. doi:10.1007/BF03022061
34. Al-Hashel J, Rady A, Massoud F, Ismail II. Post-dural puncture headache: a prospective study on incidence, risk
factors, and clinical characterization of 285 consecutive procedures. BMC Neurol. 2022;22(1):261. doi:10.1186/
s12883-022-02785-0
35. DelPizzo K, Luu T, Fields KG, et al. Risk of postdural puncture headache in adolescents and adults. Anesth
Analg. 2020;131(1):273-279. doi:10.1213/ANE.0000000000004691
36. Nath S, Koziarz A, Badhiwala JH, et al. Atraumatic versus conventional lumbar puncture needles: a systematic
review and meta-analysis. Lancet. 2018;391(10126):1197-1204. doi:10.1016/S0140-6736(17)32451-0
37. Rochwerg B, Almenawer SA, Siemieniuk RAC, et al. Atraumatic (pencil-point) versus conventional needles for
lumbar puncture: a clinical practice guideline. BMJ. 2018;361:k1920. doi:10.1136/bmj.k1920
38. Zorrilla-Vaca A, Mathur V, Wu CL, Grant MC. The impact of spinal needle selection on postdural puncture
headache: a meta-analysis and metaregression of randomized studies. Reg Anesth Pain Med. 2018;43(5):
502-508. doi:10.1097/AAP.0000000000000775
39. Heesen M, Hilber N, Rijs K, et al. Intrathecal catheterisation after observed accidental dural puncture in
labouring women: update of a meta-analysis and a trial-sequential analysis. Int J Obstet Anesth. 2020;41:71-82.
doi:10.1016/j.ijoa.2019.08.001
40. Boonmak P, Boonmak S. Epidural blood patching for preventing and treating post-dural puncture headache.
Cochrane Database Syst Rev. 2010;(1):CD001791. doi:10.1002/14651858.CD001791.pub2
41. Hung KC, Ho CN, Chen IW, et al. The impact of aminophylline on incidence and severity of post-dural puncture
headache: a meta-analysis of randomised controlled trials. Anaesth Crit Care Pain Med. 2021;40(4):100920. doi:
10.1016/j.accpm.2021.100920

JAMA Network Open. 2023;6(8):e2325387. doi:10.1001/jamanetworkopen.2023.25387 (Reprinted) August 15, 2023 13/14

Downloaded from jamanetwork.com by guest on 03/23/2024

 JAMA Network Open | Anesthesiology Consensus Practice Guidelines on Postdural Puncture Headache

42. Basurto Ona X, Osorio D, Bonfill Cosp X. Drug therapy for treating post-dural puncture headache. Cochrane
Database Syst Rev. 2015;2015(7):CD007887. doi:10.1002/14651858.CD007887.pub3
43. Melchart D, Linde K, Fischer P, et al. Acupuncture for idiopathic headache. Cochrane Database Syst Rev. 2001;
(1):CD001218. doi:10.1002/14651858.CD001218
44. Sluder G. Etiology, diagnosis, prognosis and treatment of sphenopalatine ganglion neuralgia. JAMA. 1913;61
(13_part_2):1201-1206. doi:10.1001/jama.1913.04350140117027
45. Giaccari LG, Aurilio C, Coppolino F, et al. Peripheral nerve blocks for postdural puncture headache: a new
solution for an old problem? In Vivo. 2021;35(6):3019-3029. doi:10.21873/invivo.12597
46. Chang YJ, Hung KC, Chen IW, et al. Efficacy of greater occipital nerve block for pain relief in patients with
postdural puncture headache: a meta-analysis. Medicine (Baltimore). 2021;100(51):e28438. doi:10.1097/MD.
0000000000028438
47. Lee GH, Kim J, Kim HW, Cho JW. Comparisons of clinical characteristics, brain MRI findings, and responses to
epidural blood patch between spontaneous intracranial hypotension and post-dural puncture headache:
retrospective study. BMC Neurol. 2021;21(1):253. doi:10.1186/s12883-021-02279-5
48. Chambers DJ, Bhatia K, Columb M. Postpartum cerebral venous sinus thrombosis following obstetric neuraxial
blockade: a literature review with analysis of 58 case reports. Int J Obstet Anesth. 2022;49(9200430):103218.
doi:10.1016/j.ijoa.2021.103218
49. Narouze S, Benzon HT, Provenzano D, et al. Interventional Spine and Pain Procedures in Patients on
Antiplatelet and Anticoagulant Medications (Second Edition): guidelines from the American Society of Regional
Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American
Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation
Society, and the World Institute of Pain. Reg Anesth Pain Med. 2018;43(3):225-262. doi:10.1097/AAP.
0000000000000223
50. Bauer ME, Arendt K, Beilin Y, et al. The Society for Obstetric Anesthesia and Perinatology interdisciplinary
consensus statement on neuraxial procedures in obstetric patients with thrombocytopenia. Anesth Analg. 2021;
132(6):1531-1544. doi:10.1213/ANE.0000000000005355
51. Mims SC, Tan HS, Sun K, et al. Long-term morbidities following unintentional dural puncture in obstetric
patients: a systematic review and meta-analysis. J Clin Anesth. 2022;79:110787. doi:10.1016/j.jclinane.2022.110787
52. Barad M, Carroll I, Reina MA, Ansari J, Flood P. Did she have an epidural? the long-term consequences of
postdural puncture headache and the role of unintended dural puncture. Headache. 2021;61(9):1314-1323. doi:10.
1111/head.14221
53. Sechzer PH, Abel L. Post-spinal anesthesia headache treated with caffeine: evaluation with demand method—
part 1. Curr Ther Res. 1978;24:307-312.
54. Camann WR, Murray RS, Mushlin PS, Lambert DH. Effects of oral caffeine on postdural puncture headache:
a double-blind, placebo-controlled trial. Anesth Analg. 1990;70(2):181-184. doi:10.1213/00000539-
199002000-00009
55. van Kooten F, Oedit R, Bakker SL, Dippel DW. Epidural blood patch in post dural puncture headache:
a randomised, observer-blind, controlled clinical trial. J Neurol Neurosurg Psychiatry. 2008;79(5):553-558. doi:10.
1136/jnnp.2007.122879
56. Paech MJ, Doherty DA, Christmas T, Wong CA; Epidural Blood Patch Trial Group. The volume of blood for
epidural blood patch in obstetrics: a randomized, blinded clinical trial. Anesth Analg. 2011;113(1):126-133. doi:10.
1213/ANE.0b013e318218204d
57. Scavone BM, Wong CA, Sullivan JT, Yaghmour E, Sherwani SS, McCarthy RJ. Efficacy of a prophylactic epidural
blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture.
Anesthesiology. 2004;101(6):1422-1427. doi:10.1097/00000542-200412000-00024
58. Stein MH, Cohen S, Mohiuddin MA, Dombrovskiy V, Lowenwirt I. Prophylactic vs therapeutic blood patch for
obstetric patients with accidental dural puncture–a randomised controlled trial. Anaesthesia. 2014;69(4):
320-326. doi:10.1111/anae.12562

SUPPLEMENT.
eAppendix 1. Search Summary
eAppendix 2. Full Reference List Supporting the Recommendations and Statements
eAppendix 3. The Final Level of Agreement for Each Recommendation

JAMA Network Open. 2023;6(8):e2325387. doi:10.1001/jamanetworkopen.2023.25387 (Reprinted) August 15, 2023 14/14

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