Factors associated with the onset and persistence of post-lumbar puncture headache

Abstract

Importance: This study assesses factors associated with the most common adverse event following lumbar puncture.

Objective: To identify factors associated with the risk, onset, and persistence of post-dural puncture headache (PDPH).

Design, setting, and participants: We performed univariate and multivariable analyses of 338 lumbar punctures in the Dominantly Inherited Alzheimer Network observational study using linear mixed models, adjusting for participant-level and family-level random effects.

Main outcomes and measures: We directly evaluated associations of 3 post-lumbar puncture outcomes (immediate postprocedural headache, PDPH at 24-hour follow-up, and PDPH receiving a therapeutic blood patch) with participant age and sex, positioning, collection method, needle size, needle insertion site, and cerebrospinal fluid (CSF) volume collected.

Results: The incidence of adverse events included 73 immediate postprocedural headaches (21.6%), 59 PDPHs at 24-hour follow-up (17.5%), and 15 PDPHs receiving a therapeutic blood patch (4.4%). Greater volume of CSF collected was associated with increased risk of immediate postprocedural headache, largely owing to a nonlinear increase in risk on collection of volumes above 30 mL (odds ratio, 3.73 for >30 mL and 0.98 for <17 mL). In contrast, collection of higher volumes showed a protective effect in decreasing rates of PDPH at 24-hour follow-up and rates of PDPH receiving a therapeutic blood patch (odds ratio, 0.35 per 10 mL). Although differences in needle size did not reach statistical significance, no participant in the 24G needle group received a therapeutic blood patch compared to 8 of 253 for the larger 22G needles.

Conclusions and relevance: Factors that acutely lower CSF pressure (eg, seated positioning or extracting very high volumes of CSF) may be associated with transient post-lumbar puncture headache, without increasing rates of persistent PDPH or therapeutic blood patch. Collection of up to 30 mL of CSF appears to be well tolerated and safe.

Figure

Post–Lumbar Puncture Outcomes Shown is the relative frequency of post–lumbar puncture outcomes along the y-axis plotted against cerebrospinal fluid (CSF) volume collected (A), needle size (B), and participant age (C) along the x-axis. From bottom to top, colored segments within each bar show the proportion of participants with the listed outcomes. The area of each graph segment is directly proportional to the number of individuals within that category. PDPH indicates post–dural puncture headache. Among all participants, the mean (SD) CSF volume collected was 22.32 (4.93) mL, and the mean (SD) participant age was 39.08 (10.31) years.