Special thanks to our awesome pharmacist at Cincinnati Children’s, Michelle Caruso, for help with this post.
It is enterovirus season – and with that comes viral (aseptic) meningitis. Now you may argue (correctly) that you don’t need to do an LP if your pre-test probability for bacterial meningitis is low. But say the patient already had a spinal tap and presents with a post lumbar puncture headache (AKA post dural puncture headache), the main symptoms of which include:
- Frontal or occipital headache especially worse when sitting up, better when supine
- Neck stiffness
- Visual changes
Female are more likely than males to get them, especially whose with previous history of headaches.
Things that reduce the risk of post LP headache:
- Smaller needle bore (for conventional cutting needles like the Quincke) – this is generally a greater gauge than 22G – which has the disadvantage of bending more easily
- Orientation of the bevel of a cutting needle parallel to the longitudinal fibers of the dura
- Reinsertion of the stylet before removing the needle
- Using non-cutting/pencil point spinal needles (Whitacre and Sprotte). These have a closed tip shaped like a pencil, with the hole on the side of the needle near the tip
Things that don’t significantly decrease the risk include:
- Patient positioning – including moving the sitting patient to the prone position prior to needle removal
These headaches are very concerning for patients who feel awful anyway. They can last anywhere from 2-15 days without treatment. Caffeine, a cerebral vasoconstrictor and neuro-stimulant, has long been recognized as a treatment option. In the past IV caffeine was used predominantly – 300-500mg is the dose. It is unknown if it is actually better, and recent small scale data has shown that oral caffeine (which generally comes in 300mg tablets) may be just as effective, but >120x less expensive!
So, the bottom line is – try oral caffeine for the next post LP headache you encounter. It was likely be as effective at helping the patient feel better as IV (and avoid more invasive treatments like dural blood patch). Plus, it’s much cheaper.
I’ll close out with a fun fact: A grande Pike Place from Starbucks has 330mg of caffeine. See more eye-opening numbers here…