Everything You Need To Know About Spinal Migraine

A spinal migraine, also known as spinal headache, post-dural puncture headache (PDPH), or post-spinal puncture headache (PSPH), is an intense headache that one experiences after a spinal tap (lumbar puncture) or spinal anesthesia (epidural). 

It occurs when the fluid surrounding and cushioning the brain (the cerebrospinal fluid or CSF) leaks out from the hole created after the procedure, reducing its amount around the brain. 

Although the exact mechanism of the headache is unclear, one of the three main theories is that a decrease in CSF levels causes the nerves and tissues around the brain to stretch, which leads to migraine. 

The headache usually lasts a couple of hours and resolves independently without medication. However, sometimes the headache may be intense and last several days, which may lead to your immobilization. 

When this happens, you must seek immediate medical attention. It can result in serious complications such as seizures when left untreated. 

What causes a spinal migraine?

You can develop a spinal migraine after a lumbar puncture or epidural block. The doctor conducts a lumbar puncture to diagnose neurological disorders, meningitis, and subarachnoid hemorrhage. An epidural block is performed on an expectant mother during child delivery to minimize the pain. 

During these procedures, the doctor uses a needle to obtain a sample of the CSF from the spinal cord or to deliver anesthesia. Sometimes, the spinal fluid can leak through the passage created by the needle. 

When this happens, the CSF around the brain and spinal cord is reduced, causing the brain to sag downward. The nerves and tissues around the brain can also stretch to fill the space created in the brain, thus causing headaches.

A different type of spinal headache, called low-pressure headache, can also be caused by a ruptured cyst¹ in the spinal cord or a fractured skull from a head injury, causing a leakage of the spinal fluid. 

How common is a spinal migraine?

About 10%² of people who undergo a lumbar puncture experience a spinal migraine. However, the cases are lower in epidural anesthesia since the liquid is injected instead of being drawn out of the lumbar region. 

These spinal headaches occur more in younger people from 18 to 30 years old, especially those with a lower body mass index. The headaches can range from mild to intense, depending on the amount of CSF lost. 

Symptoms of spinal migraine

After a lumbar puncture, you will most likely experience a dull headache that keeps throbbing and mostly begins in the frontal region of the head before spreading to the whole head. This pain can radiate to the neck and shoulder, resulting in a stiff neck. You may also experience stiffness when trying to move your head, and increased action may exacerbate the pain. 

The spinal headache gets better when you lie down and intensifies when you sit or stand. This is why doctors instruct patients experiencing spinal headaches to get bed rest and make sure to lay supine. Though it does not help treat the condition, it helps manage it.

You may also experience the following symptoms along with the headache:

• Dizziness

• Nausea and vomiting

• Sensitivity to light (photophobia)

• Hearing loss

• Ringing in the ears

• Neck pain or stiffness

• Seizures

• Blurred or double vision

Causes and risk factors of spinal migraine

The leading cause of spinal migraine is a “hole” in the sac around the spinal cord that causes the CSF to leak. This reduction of the cerebrospinal fluid is thought to increase the pressure exerted on the brain, leading to spinal headaches.

However, not all people who undergo a lumbar puncture suffer from a spinal headache. Several risk factors predispose a person experiencing a spinal tap to spinal headaches, including the following:

Low opening pressure

Having a low opening pressure could mean that you have a mass blocking the outflow of CSF in the spinal cord. When you have a low opening pressure, it means that there will not be enough CSF flowing to the brain or spinal cord after a lumbar puncture. This could lead to post spinal puncture headaches.

Age

Young people between the ages of 18 to 30³ are more likely to experience spinal headaches after a lumbar puncture than older people. Though there is no definite reason why this happens, one of the prominent theories is that it may be due to the enlargement of the CSF spaces.

Pregnancy

Pregnancy confers an additional risk for PDPH, possibly due to increased cerebral vasodilation in response to CSF hypotension. This can be related to high levels of circulating estrogen. 

History of chronic headaches

People who have experienced chronic headaches in the past are at risk of developing PSPH. Though there is no known relationship between chronic headaches and PSPH, the neurologic neurotransmitters and physiological characteristics of chronic headaches can make one susceptible to spinal headaches. 

However, several other studies have failed to repeat this finding.

Body mass index

Although studies are contradicting, it has historically been thought that people with a lower body mass index (BMI) are at a higher risk of developing spinal migraine than those with a higher BMI. The protective effect of a higher BMI may be secondary to the well-known positive association between BMI and CSF opening pressure.

Factors that can lead to spinal migraine after lumbar puncture

The size of the needle

The amount of CSF leaking after a lumbar puncture is directly proportional to the size of the dural tear. A small needle produces a small incision in the dura, thus minimizing CSF leakage. This, therefore, reduces the incidence of a headache. 

Though smaller needles may be satisfactory for spinal anesthesia, they might not be appropriate for a diagnostic lumbar puncture as it may take too long to collect the fluid. Therefore, a 25G needle is recommended for lumbar puncture and epidurals. 

It should also be noted that there have been studies that have failed to repeat this finding, and the data is much more heterogeneous than that for the needle design.

Needle design

To reduce spinal headaches after lumbar puncture, using non‐cutting (atraumatic) needles is recommended. These needles have a diamond-shaped (pencil point) tip, and they separate the elastic fibers instead of cutting them. 

After removing the needle, these fibers recoil, causing minor damage. This considerably reduces the occurrence of headaches.

The direction of the bevel

The collagen fibers in the lumbar region run longitudinally, parallel to the axis of the spine. To reduce the cases of headache, the doctor should insert the bevel parallel to the dura fibers instead of perpendicularly. This separates the fibers instead of cutting them, facilitating their closure. 

However, this is only of importance if using cutting needles.

Lumbar puncture attempts

The more lumbar puncture attempts, the larger the size of dura damage and the more the likelihood of spinal headache. It is, therefore, recommended that you get a maximum of four lumbar puncture attempts to decrease the possibility of post-spinal puncture headaches. 

Diagnosis of spinal headache

When you go to the doctor with complaints of spinal headaches, they will first question you about your medical history. If you previously had a spinal tap, they might recommend the proper treatment and management method without the need for other tests.

For cases with a spinal headache but no history of lumbar puncture, the doctor will recommend a magnetic resonance imaging (MRI) to establish the cause of your migraines. 

An MRI machine comprises a magnetic field and computer-generated radio waves. When you lie inside the MRI machine, the magnetic field will realign protons of the water molecules in your body. The radio waves will help the molecules create resonance, thus producing detailed anatomical images to help the doctor diagnose your condition.

Management and treatment

Since spinal headaches are common after a lumbar puncture, you must consent to the treatment, especially if you are at a higher risk of getting it. 

If you develop a spinal headache after the procedure, you should lay supine to help manage the pain. Other supporting treatments like rehydration and opioids can help you further manage the symptoms. 

Most spinal headaches occur after 24 hours of lumbar puncture and often disappear independently. If your headache persists after 72 hours since the onset of pain, you should receive the following specific treatments to help avert more serious complications.

Blood patch

Blood is drawn from your arm and injected into the epidural space in a blood patch. Once introduced, the blood clots seal the leak, thus preventing the CSF from leaking further. 

After the procedure, you will be asked to lie in a supine position for about two hours to allow the clotting to occur. This procedure is most effective when done 24 hours after lumbar puncture. However, treatment is not delayed to wait for increased efficacy and is done when the need arises.

Caffeinated drinks

Taking caffeinated drinks is not a lasting solution, but it has been historically used to relieve spinal headaches. However, studies behind caffeine in this context are lacking, though some have demonstrated benefits.

Dietary changes

Making the right dietary changes can also help manage spinal headaches. The first step is to avoid foods that trigger headaches. This includes processed foods, aged cheese, smoked fish, foods high in sodium, like potato chips, and cultured dairy products. 

Instead of the above, eat foods with high magnesium levels, as they are known to help manage headaches. Leafy greens, fresh fruits, nuts, seeds like chia and sesame, and whole grains can help manage migraines to some extent. 

Some leafy greens, fruits, and fatty fish also have anti-inflammatory benefits to help reduce inflammation and support overall well-being.

The complications of a spinal migraine

When left untreated, a spinal migraine can lead to life-threatening complications. These include the following:

• Bleeding in the skull (increased risk of subdural hematoma)

• Seizures

• Infection and bleeding in the spinal cord

• Hearing loss

• Reversible cerebral vasoconstriction syndrome

• Posterior reversible encephalopathy syndrome 

When to visit a doctor

If you develop symptoms of post-spinal puncture headaches that do not disappear after 72 hours, or if they get more intense with time, you should seek urgent medical attention. 

What questions should you ask the doctor?

When you visit your doctor regarding a spinal headache, the following questions are relevant to ask:

• What is the cause of the headache?

• How long will the headache last?

• What are the risk factors and complications for spinal headaches?

• How best can you manage spinal headaches?

The lowdown

Anybody can get spinal headaches after a lumbar puncture. That is one of the common risks of that procedure. 

If you do experience a headache, stay in bed and let the pain pass. It should go away on its own within 72 hours. After that, you can continue with your usual activities. 

If the symptoms do not subside after 72 hours, or if they get worse, seek immediate medical attention. These headaches can cause life-threatening complications like seizures if left untreated.

Getting a spinal migraine after a lumbar puncture does not mean a reduced quality of life. With proper care and treatment, you can go back to your daily life after the headaches subside.