Can Pillow Use Prevent Postdural Puncture Headache? A Critical Review

Postdural puncture headache (PDPH) is a recognized complication of neuraxial anesthesia that follows unintentional dural puncture during epidural techniques or intentional dural puncture during spinal anesthesia and other neuraxial procedures. It has traditionally been managed with a period of mandatory supine bed rest and pillow restriction, a practice grounded in the historical belief that recumbency limits ongoing cerebrospinal fluid (CSF) leakage, thereby preventing headaches. This "no-pillow" instruction remains widely taught and practiced, including among clinicians, despite an absence of literature support and evidence suggesting the opposite may be true. This review synthesizes the current literature, including randomized controlled trials, Cochrane systematic reviews, and multisociety clinical guidance, to critically examine whether pillow restriction after dural puncture reduces PDPH incidence. Evidence indicates that neither prolonged bed rest nor pillow avoidance reduces PDPH incidence and that enforced postural restriction instead increases patient discomfort, back and neck pain, and the risk of complications associated with prolonged immobilization. This review advocates the revision of institutional protocols to permit pillow use and early postoperative mobilization, as tolerated.