What Is A Spinal Headache

Introduction

A spinal headache, medically referred to as post-dural puncture headache (PDPH), emerges as a potential complication after medical procedures involving the spinal cord or lumbar puncture. The ailment can impose substantial discomfort and, at times, incapacitating distress upon afflicted individuals. Within this article, we shall embark upon an exhaustive exploration of spinal headaches, encompassing their cause, clinical manifestations, diagnostic procedures, therapeutic interventions, and preventive approaches. 

Causes of spinal headaches

The beginning of a spinal headache principally centres upon accidental dural puncture during medical procedures. This anatomical intrusion transpires when the dura mater, which is the rigid outermost envelope encasing the spinal cord, is unintentionally broken, instigating the effusion (build-up) of cerebrospinal fluid (CSF). The CSF, a transparent and colourless fluid surrounding and safeguarding the brain and spinal cord, plays a pivotal role.¹ 

• Dural Puncture in Medical Procedures: Predominantly, the catalyst behind spinal headaches remains the unintended puncture of the dura mater during clinical procedures. Such accidents  can occur  during spinal anaesthesia for obstetric purposes, the administration of epidural injections for pain management, or lumbar punctures (also known  as spinal taps) which are performed for diagnostic rationales.
• Leakage of Cerebrospinal Fluid: Upon perforation of the dura mater, an opening is established, facilitating the leakage of cerebrospinal fluid from the spinal canal. The associated reduction in CSF volume induces a decrease in intracranial pressure (space around the brain), thereby culminating in the manifestation of headaches.
• Other Causes: Although medical interventions comprise the most prevalent aetiological factor, spontaneous dural punctures may transpire due to inherent conditions like connective tissue disorders, benign intracranial hypertension, and Chiari malformations.

Symptoms and diagnosis^1,2

A spinal headache boasts distinctive attributes that distinguish it from conventional headache:

• Positional Pain: Spinal headaches, notably, tend to exacerbate when an individual assumes an upright posture and decrease when leaning back or lying down.
• Orthostatic Headache: These headaches are often characterised by throbbing severity, frequently concurrent with cervical discomfort.
• Nausea and Vomiting: These gastrointestinal symptoms may materialise as a consequence of the prevailing headache.
• Photophobia and Phonophobia: Corresponding to migraines, spinal headaches may confer photosensitivity (sensitivity to light) and phono-sensitivity (sensitivity to sound) upon the afflicted.

Accurate diagnosis of spinal headaches necessitates a judicious medical evaluation, encompassing a comprehensive review of the patient's medical history and a methodical physical examination. Notably, the "blood patch test" can serve as a confirmatory diagnostic measure.

Treatment and management²

The therapeutic repertoire for spinal headaches is contingent upon the gravity of the ailment and the consequent symptoms.

1. Conservative Modalities:
   • Bed Rest: Horizontal recumbency augments the mitigation of symptoms by diminishing cerebrospinal fluid leakage and allowing the dura mater to mend.
   • Hydration: Adequate hydration bolsters CSF volume and augments the recuperative process.
   • Caffeine Administration: Caffeine's vasoconstrictive properties may confer relief from headache symptoms.
2. Pharmacotherapy:
   • Over-the-Counter Analgesics: Non-prescription analgesics, such as ibuprofen or paracetamol, may offer respite.
   • Prescription Medications: In instances of heightened severity, potent analgesics or antiemetics may be prescribed to alleviate symptoms.
3. Epidural Blood Patch: A highly effective intervention, the epidural blood patch involves the introduction of the patient's own blood into the epidural space, instigating clot formation and subsequent sealing of the dural puncture site. This accelerates the healing process.

Recovery timeline

The majority of spinal headaches tend to get better within a span of days to a week with conservative management, while epidural blood patches conventionally prompt rapid improvement of symptoms.

Prevention 

The following measures are advised:

Mitigating Risk during Medical Procedures:

1. Needle Dimensions and Technique: Utilise fine-gauge needles and enlist the expertise of proficient practitioners to minimise dural puncture risk.
2. Needle Precision: Ensuring the accurate placement of needles is pivotal, with adjunctive utilisation of fluoroscopy aiding in precision.
3. Informed Consent: Patients ought to be apprised of the prospective risks and benefits intrinsic to spinal procedures. This reinforces patient autonomy and fosters a conscious decision-making process.
4. Post-Procedural Regimen: Post-procedurally, adherence to recumbency protocols (bed rest) is often recommended to facilitate dura mater mending e.g. surgical closures, thus attenuating the risk of developing a spinal headache.^2,3

Complications and the imperative for timely medical consultation  

Despite the generally benign nature of spinal headaches, untreated instances can give rise to complications.

• Intracranial Hypotension: Persistent cerebrospinal fluid leakage may instigate intracranial hypotension, a condition that leads to the descent of the brain within the cranial cavity. This phenomenon affects heightened symptomatology, encompassing visual discomposure, auditory alterations, and neurological deficits.³
• Prolonged Symptoms: Should a spinal headache endure for a duration exceeding one week or intensify despite conservative interventions, prompt medical evaluation is imperative for further diagnostic investigations and tailored therapeutic approaches.

A study was conducted by the International Headache Society (2020-2023) on the Recovery and long-term outcome after neurosurgical closure of spinal CSF leaks in patients with spontaneous intracranial hypotension.

A cohort of 80 surgically treated patients diligently undertook the Headache Impact Test-6 both prior to surgery and at intervals post-surgery.

The findings of this investigation are indeed promising. Preceding surgical intervention, patients grappled with severe headaches that profoundly affected their daily lives. However, within a three-month period following surgery, these patients exhibited a significant improvement in their headache-related quality of life. Furthermore, this improvement remained consistent at the 12-month follow-up. Notably, the need to recline due to symptoms considerably diminished.

In summary, the surgical closure of spinal cerebrospinal fluid leaks confers tangible and enduring relief for those afflicted by spontaneous intracranial hypotension, ultimately leading to a marked enhancement in their quality of life. Nevertheless, it is noteworthy that a subset of patients continues to contend with residual impairment, thereby underscoring the urgency of further research endeavours and explorations of potential treatment modalities. This study augments the optimism of individuals grappling with this condition, accentuating the merits of surgical intervention while reinforcing the imperative nature of continued research within this domain. ³

Recognition of warning signs 

In the event that a severe headache, neurological symptoms (e.g., aphasia or motor deficits), or flushed presentations emerge, immediate medical attention should be sought. These could indicate complications necessitating urgent medical intervention.

Summary

In summation, spinal headaches, while concealed in discomfort, are controllable via management. Familiarity with their clinical manifestations, therapeutic measures, and preventive strategies is of paramount importance for individuals embarking upon spinal procedures. By noting the guidance offered by healthcare professionals, patients can reduce the risk of succumbing to spinal headaches, thereby vastly enhancing their quality of life. Timely diagnosis and accustoming to correct and appropriate therapeutic regimens are pivotal requirements.

FAQs

How do you know if you have a spinal headache?

A spinal headache is typically characterised by a specific set of symptoms. The key indicator is that the headache worsens when you sit or stand and improves when you lie down. It's often accompanied by neck pain and can be throbbing in nature.

How do you fix a spinal headache?

Treatment options for spinal headaches include bed rest, hydration, caffeine intake, over-the-counter pain relievers, prescribed medications, and, in severe cases, an epidural blood patch. Consult a healthcare professional for a proper diagnosis and treatment plan.

What does a spinal fluid headache feel like?

A spinal fluid headache often feels like a severe, throbbing headache. It's typically located at the back of the head or in the neck region and is known to be highly positional, worsening when upright and improving when lying flat.

What causes headaches in the spine?

Spinal headaches are primarily caused by dural punctures during medical procedures, which lead to a leakage of cerebrospinal fluid (CSF). These procedures may include spinal anaesthesia, epidurals, or lumbar punctures.

How serious is a spinal headache?

While spinal headaches are generally benign, they can be very uncomfortable and debilitating. Serious complications can arise if left untreated, making it important to seek medical attention if symptoms persist or worsen.

What happens if a spinal headache is untreated?

If left untreated, a spinal headache can lead to intracranial hypotension, a condition where the brain sags downward within the skull. This can result in more severe symptoms and complications.

Is a spinal headache an emergency?

While spinal headaches are not typically considered emergencies, severe symptoms, neurological changes, or high fever may warrant immediate medical attention.

Does a spinal headache feel like a migraine?

Spinal headaches may share some similarities with migraines, such as sensitivity to light and sound. However, their positional nature and connection to medical procedures distinguish them.

Can stress cause spinal headaches?

Stress is not a direct cause of spinal headaches. These headaches are primarily associated with dural punctures during medical procedures. However, stress can exacerbate headache symptoms in general.

What are the symptoms of a CSF leak (Cerebrospinal Fluid Leak) according to the NHS?

The common symptoms of a CSF leak can include a persistent and severe headache, neck pain, tinnitus (ringing in the ears), a metallic taste in the mouth, and clear, watery nasal discharge. If you suspect a CSF leak, consult a healthcare provider for evaluation and diagnosis.