Postdural puncture headache: Beyond the evidence

Despite advances in procedural techniques and equipment, postdural puncture headache (PDPH) remains a serious complication of labour epidural analgesia after accidental dural puncture (ADP). Often considered a temporary inconvenience, PDPH can be debilitating in the short term. It can also be associated with chronic manifestations and serious complications. The precise underlying mechanisms of PDPH are still incompletely understood, and longstanding beliefs of dysregulation of cerebrospinal fluid (CSF) homeostasis due to CSF fluid loss are currently being challenged. The existence of orthostatic headaches unrelated to CSF loss demands consideration of other mechanisms involved, for instance, related to the autonomic nervous system or the release of calcitonin gene-related peptide (CGRP) associated with activation of the meningeal and cerebral arteries. A multi-society international working group recently provided evidence-based recommendations on the prevention, diagnosis, and management of PDPH resulting from neuraxial procedures. According to the recommendations, there was insufficient evidence to support the routine use of intrathecal catheters or sphenopalatine ganglion blocks to prevent or treat PDPH. Both evidence-based and experimental strategies include stabilizing CSF dynamics through preventing CSF loss, supplementing CSF, or increasing production, and reducing cerebral vasodilation. Future research in PDPH preventive and therapeutic strategies can be facilitated with standardised definitions, interventions, and outcome measures. Analyses should consider various confounding factors and recognise the complex multifactorial nature of pain experience across diverse populations. Clinical care and research on PDPH will demand a multidisciplinary collaborative effort to elucidate the complexities of its pathophysiology and further improve patient outcome and quality of care.