[Prevention and treatment of headache due to intracranial hypotension]

In spite of the large number of authors who have studied headache following lumbar puncture and spontaneous intra-cranial hypotension, many aspects remain little known, and there is still no completely satisfactory non-invasive treatment.

In one group of patients there is an increased risk of post lumbar-puncture headache: adults between 20 and 50 years old, of low body weight and a previous history of chronic bilateral headache. In these patients all possible prophylactic measures should be taken whilst the lumbar puncture is being performed, so as to avoid the onset of headache. Use of modern atraumatic needles of small diameter and with a lateral opening have been shown by many studies to be satisfactory. There are also other manoevres which help to reduce the frequency of post lumbar-puncture headache, such as the insertion and withdrawal of the needle with the bevel parallel to the fibres of the dura mater and reinsertion of the stylet before withdrawing the needle. Once the patient has developed post lumbar-puncture headache, or spontaneous intracranial hypotension, initially treatment with cerebral vasoconstrictors such as oral caffeine may be used. After a period of time (2-4 weeks) which makes spontaneous regression of the headache unlikely, the treatment of choice involves epidural patches.

Well-designed studies are necessary to demonstrate the efficacy of oral caffeine (and other drugs) in post lumbar-puncture headache.