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

JAMA Neurol. 2015 Mar;72(3):325-32. doi: 10.1001/jamaneurol.2014.3974.


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.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Blood Patch, Epidural / trends*
  • Female
  • Follow-Up Studies
  • Humans
  • Linear Models
  • Male
  • Middle Aged
  • Post-Dural Puncture Headache / diagnosis*
  • Post-Dural Puncture Headache / etiology
  • Post-Dural Puncture Headache / therapy*
  • Retrospective Studies
  • Risk Factors
  • Spinal Puncture / adverse effects*
  • Spinal Puncture / trends*
  • Time Factors