Clinical Neurology and Neurosurgery 131 (2015) 78–81

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Risk factors for post lumbar puncture headache Alexander Khlebtovsky a,b,∗ , Sherry Weitzen b , Israel Steiner a,b , Arie Kuritzky a,b , Ruth Djaldetti a,b , Shlomit Yust-Katz a,b a b

Department of Neurology, Rabin Medical Center, Petach Tikva, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

a r t i c l e

i n f o

Article history: Received 27 June 2014 Received in revised form 13 January 2015 Accepted 28 January 2015 Available online 7 February 2015 Keywords: Headache Lumbar puncture Post lumbar puncture headache Anxiety Risk factors

a b s t r a c t Background: Lumbar puncture (LP) is complicated by headache in about one-third of patients. The aim of the study was to evaluate potential risk factors for post-LP headache. Methods: 144 Patients undergoing diagnostic LP at a tertiary medical center completed questionnaires on fear of the procedure, pre-existing headache, and post-LP headache. Data on patient demographics, operator experience, and other procedure-related parameters were collected from hospital files. Results: The post-LP headache group (n = 37, 27.6%) was characterized by a significantly younger age and higher proportion of women relative to the no-headache group (n = 97); body mass index was similar. Both groups had similar levels of fear of the procedure and there was no correlation between intensity of patients’ anxiety to the procedure and its occurrence. Patients with high opening pressure had higher levels of post-LP headache (28.6% vs. 18% p = 0.078) and a history of headaches was significantly more prevalent in the post-LP-headache group (66.6% vs. 38.1%, p = 0.003). Conclusions: Fear of the procedure does not predispose to occurrence of post-LP headache while a history of headache and elevated intracranial pressure does. These findings may be related to the possible pathophysiology of the condition, namely a change in compliance and pressure gradients with resultant venous distention. © 2015 Elsevier B.V. All rights reserved.

1. Introduction Lumbar puncture (LP) is a common diagnostic, therapeutic, and anesthetic procedure. It is complicated by headache in about onethird of patients [1]. Post-LP headache is typically postural and may be accompanied by nausea, vomiting, tinnitus, and hearing impairment. It usually lasts for a couple of days, is dull or throbbing and varies in severity from mild to severe enough to immobilize the patient and to require therapy [2,3]. The post-LP headache is presumed to be caused by leakage of cerebrospinal fluid (CSF) through the dural puncture site, which reduces intracranial pressure and leads to traction on pain-sensitive intracranial structures with consequent venous distension [4]. Several demographic factors have been associated with post-LP headache, namely young age and female sex. Some studies reported that young women with a low body mass index (BMI) had the highest risk of post-LP headache [2,5,6], whereas others found no effect of BMI [7]. Procedural measures that might be effective in reducing the occurrence of headache include use of a small-sized needle,

reinsertion of the guide before needle withdrawal, and directing the bevel perpendicular to the dura [2,8,9]. Among the factors found to have no significant effect on post-LP headache are volume of the spinal fluid removed, bed rest (or not) after LP, patient position during the procedure (supine or sitting), opening pressure, and CSF constituents [1,10,11]. However, data on the possible effect of patient anxiety before the procedure [12–14] and operator experience is not available [2]. In addition, few studies have examined the role of pre-existing headache(s). One study found that patients who had a history of chronic or recurrent headaches were three times as likely to acquire a post-LP headache than patients who did not [15]. Another, identified a history of recent headache (within seven days) as a risk factor for post-LP headache [2]. The aim of the present study was to look for risk factors that predispose to the development of post-LP headache. Besides parameters that were already examined we focused on two that were not addressed before: level of anxiety before the LP procedure and the impact of operator experience.

2. Methods ∗ Corresponding author at: Department of Neurology, Rabin Medical Center, Petach Tikva 49100, Israel. Tel.: +972 3 937 6358; fax: +972 3 937 8220. E-mail address: [email protected] (A. Khlebtovsky). http://dx.doi.org/10.1016/j.clineuro.2015.01.028 0303-8467/© 2015 Elsevier B.V. All rights reserved.

Patients admitted to the Department of Neurology of a tertiary medical center and underwent a diagnostic LP between January

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2008 and January 2010 were asked to complete a questionnaire before and after the LP. All the procedures were performed using traumatic type (Quinke needle) (Becton Dickinson S. A. S Augustin del Guadalix. Madrid. Spain). The patient was in lying or sitting position. The procedure was performed in a midline approach, at the L4–L5 intervertebral space level. The pretest questionnaire included items on history of headache episodes before the acute illness for which they were admitted, presence of headache during the current acute illness, and the characteristics of the headache(s) (if present): quality, location, severity (rated on a scale from 1 to 10), and postural nature (worse when standing up or lying down), and associated symptoms (nausea, vomiting, tinnitus). In addition, participants were asked to rate their fear of the LP test on a scale from 0 (no fear) to 10 (extreme fear). The post-LP questionnaire included items on the presence of headache at 6 and 24 h after LP, location of the headache (when present), quality and severity of the headache (rated as in the pretest questionnaire), postural nature of the headache, and associated symptoms (as in the pretest questionnaire). Data on patient characteristics (age, sex, height, weight) were collected from the medical files, and body mass index (BMI) was calculated (weight (kg)/(height (m)) [2]. Procedure-related data, including indications for the test, needle size (22G or 20G), opening pressure, number of punctures, data on the years of experience of each of the operators who performed the test (recorded for the study as more or less than 1 year) were obtained. CSF content (cells, glucose, protein), were collected from hospital records. Although the whole questionnaire was not validated, pain and fear intensity was evaluated using VAS score. Other parts of the questionnaire included questions regarding the clinical characteristics of post-LP headache. Post-LP headache was defined according to the International Headache Society (IHS) [16] as a headache of intensity >3 that occurred within to 24 h after the procedure and improved with rest. In patients with a pre-LP headache, any headache after LP was considered procedure-related if it differed in quality or location from the pre-LP headache. The study was approved by the local ethical committee, and all participants signed a written informed consent form.

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Table 1 Characteristics of 144 patients with or without headache after lumbar puncture. Headache

No headache

Number of patients Age (yr) (mean ± SD) Female Male BMI (mean) Fear of LP (mean* ) Headache immediately before LP History of headache† Operators experience ≤1 yr Operators experience >1 yr No stabs (mean ± SD) Needle size 22G Needle size 20G Opening pressure (cm H2 O) mean ± SD

37 (27.6%) 40.1 ± 16.4 24 (65%) 13 (35%) 26.6 5.5 14 (38%) 24 (67%) 12 (32.4%) 25 (67.6%) 1.8 ± 2.1 14 (38%) 23 (62%) 22 ± 7.6

97 (72.4%) 46.4 ± 16.5 49 (50%) 48 (49%) 26.3 5.1 42 (43%) 37 (38%) 32 (34.4%) 61 (65.6%) 2.1 ± 2.17 31 (32%) 65 (68%) 18.8 ± 6.8

p Value

NS NS NS 0.003 NS NS NS NS NS NS

CSF content (mean ± SD) Cells Glucose (mg/dL) Protein (mg/dL)

17.5 ± 58 63.3 ± 10 38.3 ± 22.5

24 ± 11 69.4 ± 17.7 44.6 ± 30.5

NS NS NS

0.0496 0.136**

Values are in numbers (%) or mean ± SD. BMI—body mass index, CSF—cerebrospinal fluid, NS—non significant. * Rated on a scale from 0 (no fear) to 10 (extreme fear). ** Comparing female with post LP headache with male with post LP headache. † Headache episodes prior to acute illness that was the reason for the present admission.

2 , so as comparison between percentage of post-LP headache between group with elevated and normal opening pressure. Odds ratios for post-LP headache for all baseline factors were calculated by Logistic Regression. Factors found to be significantly different between the groups were entered into a multivariate logistic regression model, controlling for potential confounders, to identify independent associations with post-LP headache. The statistical analysis was generated using SAS Software, Version 9.4 of the SAS System for PC, Copyright 2002–2012. SAS and all other SAS Institute Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc., Cary, NC, USA.

2.1. Statistical analysis 3. Results Means and standard deviations were calculated for continuous variables and differences between patients with and without postLP headache were analyzed by two-sample t-tests. For binary and nominal variables, proportions were calculated, and p values were computed using Pearson chi-square test (for variables with more than 5 observations per group) or Fisher exact test (for variables with less than 5 observations in one or both groups). Comparison between percentages of post LP headache in the various neurological disorders was done using Pearson chi-square test. Comparison between groups of patients with high and low level of fear, high and low headache intensity before LP was done using

3.1. Group characteristics (Table 1) The study sample included 144 patients, 72 men and 72 women of mean age 44.6 years (range 19–84). Thirty-seven patients (27.61%) reported post-LP headache (IHS definition). The characteristics of the patients with and without headache are shown in Table 1. The headache group was characterized by a lower mean age (40.12 ± 16.4 vs. 46.4 ± 16.5 years, (p < 0.05)) and a higher proportion of women (65% vs. 50%). There was no difference in BMI between the groups.

Table 2 Characteristics of patients and incidence of post-LP headache according to indication for LP. Indication for LP (N)

Age

Sex (F)

BMI

Chronic headache (%)

Headache before LP (%)

Post-LP headache (%)

Headache (17) Demyelination (20) Dementia (7) Meningitis (11) Polyneuropathy (19) Idiopathic intracranial hypertension (14) Diplopia (8) Myeloencephalitis (8) Other* (29)

38.7 40.9 64 36.04 57.17 29.5 49.75 42.13 48.1

11/17 12/20 1/7 8/11 5/19 11/14 6/8 48 14/29

24.47 24.68 25.49 27.41 26.62 34.58 23.15 23.94 26.21

64 40 42 37 21 57 75 25 35

64 35 28 90 15.7 50 37.5 37.5 20.6

11 25 14 36 15 35 28 12.5 13

BMI—body mass index. * Other—plexitis, infiltration, ataxia, positive blood VDRL test, myelopathy, motor neuron disease.

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Ten different operators performed the LP procedure in the 144 study patients. Analysis yielded no statistically significant between-group differences in operator experience, size of the needle used, and number of stabs. This was also true for opening pressure and CSF content. A history of headaches before the acute illness for which they were admitted was reported by 67% of the post-LP headache group and 38% of the no-headache group; this difference was statistically significant (p = 0.003). The frequency of the headaches ranged from daily (22%) to once a week (39%), to once a month (30%). The patients described their headaches as dull, throbbing, or tensiontype. The frequency of headache at the time of the LP (during the acute illness immediately before the test) was not significantly different between the two groups (38% vs. 43%, p = 0.57). 3.2. Occurrence of post-LP headache by disease and CSF parameters (Table 2) The highest rates of post-LP headache were seen in patients with pseudotumor cerebri (35.71%) and meningitis (36.6%). These were also the patients with high level of fear prior to LP (6.4 and 5, respectively). The 17 patients who underwent LP for the evaluation of headache in which there was no evidence for specific pathology were also anxious (7 on the scale) but tended not to develop post-LP headache. 3.3. Extent of fear, elevated intracranial pressure and headache intensity and post-LP headache (Tables 1 and 3) When the mean level of fear of LP was compared between patients with and without post-LP headache groups irrespective of the disease process, no difference was observed (Table 1). Likewise, no significant difference was found comparing percentage of post-LP headache in patients with high (5–10) and low (0–4) degree of fear before LP. (Table 3, 19.51% vs. 20.4%; p = 0.9). When comparing patients with high opening pressure (opening pressure more than 22 cm H2 O) to patients with normal opening pressure (opening pressure less than 22 cm H2 O) there was a trend for significant difference between those two groups at numbers of post-LP headache (Table 3, 28.56% vs. 18% p = 0.078). No significant difference at incidence of post-LP headache was found comparing patients with high grade (5–10 VAS scale) and low (0–4 VAS scale) headache intensity before LP (Table 3, 19.4% vs. 20.62%; p = 0.955). Likewise, the extent of fear did not impact occurrence of post-LP headache. When the two factors found to be significant on bivariate analysis (age, history of headache) were entered into a multivariate regression model, only history of headaches retained significance. Specifically, patients with a history of headache episodes prior to the acute event/admission had 3.1 times the odds of having a postLP headache than patients without a history of headaches (95% CI: 1.34–7.15). 4. Discussion The 27.6% incidence rate of post-LP headache in the present study was similar to values reported before [1], validating our patient sample. Moreover, our cohort of patients’ distribution by disease is representative of the population undergoing diagnostic LP in a neurology department (Table 2) [17]. The etiology and pathogenesis of post-LP headache are unknown. Three main theories were proposed: (i) continuous CSF leak after LP [18] with sagging of the brain and distension of dural venous sinuses and dura [19]; (ii) venous distension with resultant orthostatic headache following LP [20]; (iii) changes in compliance of caudal and rostral parts of the CNS, that create

Table 3 Association of post-LP headache with elevated intracranial pressure, headache intensity and extent of fear.

Opening pressure >22 cm H2 O Opening pressure < 22 cm H2 O Headache intensity 5–10 Headache intensity 0–4 Intensity of fear before LP 5–10 Intensity of fear before LP 0–4

Patients with post LP headache

Patients without post LP headache

p-Value

6 (28.56%) 9 (18%) 7 (19.4%) 16 (20.62%) 16 (19.51%) 10 (20.4%)

15 (71.44%) 41 (82%) 29 (80.6%) 66 (79.38%) 66 (80.49%) 29 (79.6%)

p = 0.078 p = 0.955 p = 0.9

intracranial hypotension [21]. The last possibility may explain the higher incidence of post-LP headache in patients with idiopathic intracranial hypertension (higher  of pressures between caudal and rostral areas) and also the higher incidence of post-LP headache in patients with meningitis (changes at dura elasticity because of inflammation) and multiple sclerosis (changes of content of the CSF because of inflammation) compared to other neurological disorders (Table 2). The present study supports earlier findings for two risk factors, including young age and female sex (Table 1) [2,5,6], although the between-group difference of sex in our study achieved only trend level. We noted no correlation of post-LP headache with low BMI (Table 1), in agreement with one study [7] but not with others [5,6]. However, our post-LP headache group included some patients with idiopathic intracranial hypertension and a BMI of more than 40, which may have influenced the results. The novelty of this study was that we explored the relationship between level of anxiety before lumbar puncture and the rate of post-LP headache after the procedure. This relationship was never tested before. We hypothesized that patient’s tension and lack of relaxation during the procedure can lead to excessive CSF leak and, as a result, to post-LP headache. The hypothesis that was the base of our study was refuted by the findings. We found that the level of fear of the procedure was similar in patients who had post-LP headache and those who did not (Table 1). Also no differences were found between patients with high and low level of fear (Table 3). Few and conflicting data have been reported on the effect of psychogenic factors on the risk of post-LP headache. Some studies showed that post-LP headache occurred much more frequently in patients who expressed concern about this complication (46% compared to 11%) [12], others showed the opposite [13,14]. Our findings suggest that whatever the possible pathophysiology of post-LP syndrome, psychological aspects do not play an important role in its causation. We found that pre-LP episodes of headache were a risk factor for post-LP headache (Table 1) irrespective of headache intensity (Table 3). Accordingly, a previous study reported that a history of chronic or recurrent headache was associated with three times the likelihood of development of post-LP headache [15]. This finding also supports the theory of a vascular component in post-LP headache pain. If decrease in intracranial pressure after LP leads to intracranial venous distension, patients with a history of headache, especially vascular type (migraine, toxic, cluster), may be more susceptible to the development of post-LP headache [4]. Our finding that operator experience is unrelated to the risk post-LP headache is in line with another study [2]. Likewise, the lack of effect of needle type on post-LP headache might be explained by bias in selecting needle size [7,14]. Other factors not associated with post-LP headache in our study were indication for the test, opening pressure, CSF content, and bed rest after the test (data not shown). In conclusion, fear of the procedure does not predispose to occurrence of post-LP headache while a history of headache and elevated intracranial pressure does. These findings may be attributed to changes in compliance and pressure gradients with resultant venous distention causing this type of headache.

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Risk factors for post lumbar puncture headache.

Lumbar puncture (LP) is complicated by headache in about one-third of patients. The aim of the study was to evaluate potential risk factors for post-L...
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