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How to Prevent Post-LP Headaches

June 23, 2021

Written by Carmen Wolfe

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Risk for post-LP headache can be lessened by using atraumatic non-cutting needles, which, contrary to popular belief, are not more difficult to use than traditional cutting needles. Utilizing the lateral decubitus position, a higher intervertebral space, and orienting the needle bevel parallel to the spinal axis may also decrease risk. Other common recommendations, including IV fluids, caffeine, and bed rest are unlikely to help.

Why does this matter?
Lumbar puncture (LP) is a common ED procedure, and the risk for post-LP headache is reported anywhere from 3-33%. We can’t change some factors that are associated with this complication, such as female sex, lower BMI, younger age, and history of headaches. But, there are many other factors that are under our control such as needle choice, procedure technique, and post-procedural recommendations.

Less pain from the puncture
This article reviewed literature from 2000-2020 to evaluate headache in patients after diagnostic lumbar puncture. Nineteen FAQs in four major categories regarding post-LP headache were identified, and the answers were determined along with a rating of the available evidence for each question. The table in this article gives a great summary; here’s an even shorter one below:

  • Who is at increased risk?  Female sex, lower BMI, younger age, and history of headaches may lead to increased risk.

  • Which needle should I use? Atraumatic needles are definitely effective to reduce this complication and are not more difficult to use.

  • What specific technique should I use? Lateral decubitus position, a higher intervertebral space, and orientation of the bevel parallel to the spinal axis are all possibly associated with lower risk. Difficult taps, higher volume taps, and aspirating CSF do not increase risk.  The jury is still out on needle diameter and stylet reinsertion.

  • What can I do after the LP to reduce this risk? IV fluids and caffeine do not reduce risk. Bed risk doesn’t reduce risk and may actually increase it; evidence favors immediate mobilization. More research is needed to determine if pharmacologic agents such as  frovatriptan, morphine, cosyntropin, or aminophylline might be helpful.

Preventing Post-Lumbar Puncture Headache. Ann Emerg Med. 2021 May 6;S0196-0644(21)00151-7. doi: 10.1016/j.annemergmed.2021.02.019. Online ahead of print.

What are your thoughts?