Refractory Post-dural Puncture Headache: A Case Series on Presenting Symptoms, Imaging Findings, and Treatment
Objective:
This study aims to characterize refractory post-dural puncture headache (PDPH), a condition that may persist long after obstetric anesthesia procedures, potentially manifesting differently from the acute form and may not be recognized given the latency of presentation.
Background:
Acute post-dural puncture headache (PDPH) following obstetric anesthesia is well-documented. However, a subset of women may develop refractory PDPH even years later, resembling other headache phenotypes and evading diagnosis.
Design/Methods:
We conducted a retrospective analysis of medical records for six women with a new headache diagnosis in the post-partum period 2019 to 2023. Patients were referred to a subspecialty CSF leak clinic between 5 days and 3.5 years post-delivery. All women had evidence of CSF leakage on neuroimaging and did not carry a diagnosis of headache prior to labor epidural. Data collected included demographics, delivery and anesthesia modes, presenting symptoms, imaging findings, and treatments.
Results:
The study comprised six women with an average age of 31 years. One woman underwent a cesarean delivery, while the rest had vaginal deliveries. One patient received spinal subrachnoid anesthesia, and five had epidural anesthesia. In 5 cases, anesthesia notes indicated multiple attempts, and one noted a dural puncture. Common presenting symptoms included orthostatic headache and neck pain. Imaging findings revealed signs of intracranial hypotension and spinal extradural fluid collections. Four patients received up to two empiric blood patches, with all six subsequently requiring image-guided targeted patches. 50% experienced complete symptom resolution, and the other 50% reported partial symptom reduction.
Conclusions:
While PDPH is well-recognized in the immediate postpartum period, our study highlights a subset of women who develop refractory and even chronic PDPH related to obstetric anesthesia events. This condition may not become evident for months to years, and affected individuals may exhibit distinct symptoms, imaging features, and treatment requirements. Understanding these variations is crucial for accurate diagnosis and management.