Lumbar Puncture: Heading Off the Dreaded Headache

Biochemical markers in cerebrospinal fluid (CSF) are proving increasingly useful in clinical diagnosis and research, but having people agree to a lumbar puncture can be a challenge, particularly in the United States. Just the thought of that needle sends chills down some people's spines, and others fear the headache that sometimes follows. Is there a way to minimize that side effect? Reporting in the January 26 JAMA Neurology, scientists led by Randall Bateman, Washington University School of Medicine, St. Louis, report on CSF collection methods likely to bring on headaches, either right after the procedure or over the following week. While the volume of CSF collected emerged as the biggest factor, needle size and posture during the procedure may also contribute.

“This gives good evidence that there may be different factors that lead to immediate versus the more serious, longer-term headaches,” said Krista Moulder of WashU.

Headaches that arise soon after the tap may result from a drop in CSF pressure due to the volume pulled from the system. This causes blood vessels of the central nervous system to dilate temporarily, putting pressure on sensitive tissues that surround the brain, and perhaps causing friction on cranial nerves. Lying down usually relieves the problem. Since the brain makes about 20 ml of CSF per hour, it quickly replaces the lost fluid and these pains fade fast. In contrast, a headache that develops over the next few days is thought to come from continued CSF leakage through a tear in the dura mater—the membrane that surrounds the spinal cord—although it is not clear how this causes headache (see Sakurai et al., 2013). If the discomfort persists, a person can be treated with a blood patch, where the doctor injects a bolus of the patient’s blood just above the puncture to clot and plug the leak.

To examine factors that lead to the different types of headache, first author Andrés Monserrate, University of Puerto Rico School of Medicine, San Juan, examined records of 338 lumbar punctures conducted in the Dominantly Inherited Alzheimer Network (DIAN) observational study, a multicenter research trial of people at risk for autosomal-dominant Alzheimer’s disease. The trial specifies a protocol for collecting CSF, but allows for some flexibility. For instance, patients can give CSF lying down or sitting up, researchers can draw CSF with a 22- or 24-gauge needle, and they can insert it in one of several spots. They are supposed to collect a minimum of 17 ml, though volumes in this study varied from 3 to 33 ml. The scientists followed up with each patient by phone in the days after the procedure.

The 338 people who received lumbar punctures averaged 40 years in age, ranging from about 20 to 70. About 22 percent got a headache right after the procedure, 17.5 percent developed one after 24 hours, and 4.4 percent received a blood patch. How much CSF was withdrawn appeared to be the biggest factor in whether a headache ensued. Immediate headaches occurred more often in people who gave more than 30 ml, possibly because of the rapid drop in CSF pressure. Most of those giving less than 17 ml were fine right after the tap, but more likely to have a headache the next day. In those cases, CSF may continue to leak through the puncture after the needle is withdrawn because the fluid’s pressure is still relatively high, suggested the authors. This may prevent the dural tear from healing. Taking between 17 and 30 ml may be safest, they proposed.

Unsurprisingly, perhaps, the size of the needle may also play a role. Compared with the 22-gauge needle, the smaller 24-gauge was associated with fewer headaches overall and required no blood-patch treatments. The smaller hole left by the smaller needle may heal more easily. Giving CSF in a seated position also trended toward higher rates of immediate headache, possibly because the drop in CSF pressure is more pronounced in the upright position.

Various studies have placed the incidence of headache after lumbar puncture between 0.1 and 36 percent (see Jabbari et al., 2013), and the numbers reported here are within that range. A recent prospective study tracked complications after lumbar puncture in 689 patients from memory units in Spain, finding a 24.8 percent incidence of headache (see Alcolea et al., 2014). They found that younger age and the use of cutting needles—which cut through the tissue, rather than spreading it open—associated with higher risk.

Reports of low incidence likely include older participants, whose risk of spinal tap headache is generally lower, researcher agreed (see van Oosterhout et al., 2013). For instance, a study in Sweden reported that only 2.6 percent of 1,089 people who averaged 70 years of age got headaches after a spinal tap (see Zetterberg et al., 2010). Henrik Zetterberg, University of Gothenburg, who co-authored the study, added that the researchers asked patients to call back to report any symptoms, rather than following up with each one individually. While this could have underestimated the true incidence, the follow-up used in the current paper could lead to false positives, he wrote to Alzforum. He remarked that the study corroborates the safety of lumbar punctures and that up to 30 ml seems reasonable to take. That amount will enable more research at no increased cost, he noted.

Cynthia Carlsson, University of Wisconsin, Madison, thought that the headache frequency after 24 hours seemed high compared to the 2 percent rate she sees at her institution, where participants average about 52 years of age. She suggested that an even smaller, 25-gauge needle, and the use of gentle aspiration rather than relying on gravity, reduces the time the needle pierces into the subarachnoid space and hence lowers the chance of a dural tear. She said most of her study participants do not have Alzheimer’s disease, and that perhaps something about AD pathology may heighten the risk for headache. “Evaluating these procedures in various populations will help us arrive at standardized collection approaches, which may differ depending on age or presence of disease,” she told Alzforum.

“Every study that demonstrates the tolerability and safety of lumbar puncture is a huge benefit to the field,” said Moulder. While academics consider it safe, many patients and even physicians hesitate to use it. This paper demonstrates that the vast majority of patients experience no side effects, Moulder noted. Led by John Morris, also at WashU, and Walter Kukull, University of Washington, Seattle, Moulder is conducting a prospective study to examine incidence of complications after lumbar puncture from multiple centers in the United States (see Aug 2010 webinar). They will consider the cognitive status of the patient, attitude of patient and physician, needle type used, collection of CSF by aspiration or gravity, and experience of the physician. They plan to present their preliminary findings at the upcoming Alzheimer’s Association International Conference.—Gwyneth Dickey Zakaib

Comments

No Available Comments

Make a Comment

To make a comment you must login or register.

References

Webinar Citations

  1. Untapped Resource? New Study to Boost Acceptance of CSF Analysis

Conference Citations

  1. Alzheimer's Association International Conference 2015

Paper Citations

  1. Sakurai K, Matsukawa N, Okita K, Nishio M, Shimohira M, Ozawa Y, Kobayashi S, Yamawaki T, Shibamoto Y. Lumbar puncture-related cerebrospinal fluid leakage on magnetic resonance myelography: is it a clinically significant finding?. BMC Anesthesiol. 2013 Oct 27;13(1):35. PubMed.
  2. Jabbari A, Alijanpour E, Mir M, Bani Hashem N, Rabiea SM, Rupani MA. Post spinal puncture headache, an old problem and new concepts: review of articles about predisposing factors. Caspian J Intern Med. 2013;4(1):595-602. PubMed.
  3. Alcolea D, Martínez-Lage P, Izagirre A, Clerigué M, Carmona-Iragui M, Alvarez RM, Fortea J, Balasa M, Morenas-Rodríguez E, Lladó A, Grau O, Blennow K, Lleó A, Molinuevo JL. Feasibility of lumbar puncture in the study of cerebrospinal fluid biomarkers for Alzheimer's disease: a multicenter study in Spain. J Alzheimers Dis. 2014;39(4):719-26. PubMed.
  4. van Oosterhout WP, van der Plas AA, van Zwet EW, Zielman R, Ferrari MD, Terwindt GM. Postdural puncture headache in migraineurs and nonheadache subjects: a prospective study. Neurology. 2013 Mar 5;80(10):941-8. Epub 2013 Feb 6 PubMed.
  5. Zetterberg H, Tullhög K, Hansson O, Minthon L, Londos E, Blennow K. Low incidence of post-lumbar puncture headache in 1,089 consecutive memory clinic patients. Eur Neurol. 2010;63(6):326-30. PubMed.

Further Reading

Papers

  1. Molinuevo JL, Blennow K, Dubois B, Engelborghs S, Lewczuk P, Perret-Liaudet A, Teunissen CE, Parnetti L. The clinical use of cerebrospinal fluid biomarker testing for Alzheimer's disease diagnosis: a consensus paper from the Alzheimer's Biomarkers Standardization Initiative. Alzheimers Dement. 2014 Nov;10(6):808-17. Epub 2014 Aug 20 PubMed.
  2. Blennow K, Dubois B, Fagan AM, Lewczuk P, de Leon MJ, Hampel H. Clinical utility of cerebrospinal fluid biomarkers in the diagnosis of early Alzheimer's disease. Alzheimers Dement. 2014 May 2; PubMed.

Primary Papers

  1. Monserrate AE, Ryman DC, Ma S, Xiong C, Noble JM, Ringman JM, Morris JC, Danek A, Müller-Sarnowski F, Clifford DB, McDade EM, Brooks WS, Darby DG, Masters CL, Weston PS, Farlow MR, Graff-Radford NR, Salloway SP, Fagan AM, Oliver A, Bateman RJ, Dominantly Inherited Alzheimer Network. Factors associated with the onset and persistence of post-lumbar puncture headache. JAMA Neurol. 2015 Mar;72(3):325-32. PubMed.

Annotate

To make an annotation you must Login or Register.