Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report

Key Points

Question  To improve care and enhance patient safety, how should clinicians attempt to prevent, diagnose, and manage postdural puncture headache (PDPH)?

Findings  In this consensus statement, a multidisciplinary panel of 21 collaborators outlined recommendations for the prevention, identification, and management of PDPH. The strength and certainty of evidence of various patient, procedural, diagnostic, and management aspects of PDPH were graded.

Meaning  These practice guidelines provide a framework for individual clinicians to assess risk, confirm diagnosis, and adopt a systematic approach to management of PDPH.

Importance  Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures, such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis, and management of this condition is, however, currently lacking.

Objective  To fill the practice guidelines void and provide comprehensive information and patient-centric recommendations for preventing, diagnosing, and managing PDPH.

Evidence Review  With input from committee members and stakeholders of 6 participating professional societies, 10 review questions that were deemed important for the prevention, diagnosis, and management of PDPH were developed. A literature search for each question was performed in MEDLINE on March 2, 2022. Additional relevant clinical trials, systematic reviews, and research studies published through March 2022 were also considered for practice guideline development and shared with collaborator groups. Each group submitted a structured narrative review along with recommendations that were rated according to the US Preventive Services Task Force grading of evidence. Collaborators were asked to vote anonymously on each recommendation using 2 rounds of a modified Delphi approach.

Findings  After 2 rounds of electronic voting by a 21-member multidisciplinary collaborator team, 47 recommendations were generated to provide guidance on the risk factors for and the prevention, diagnosis, and management of PDPH, along with ratings for the strength and certainty of evidence. A 90% to 100% consensus was obtained for almost all recommendations. Several recommendations were rated as having moderate to low certainty. Opportunities for future research were identified.

Conclusions and Relevance  Results of this consensus statement suggest that current approaches to the treatment and management of PDPH are not uniform due to the paucity of evidence. The practice guidelines, however, provide a framework for individual clinicians to assess PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management.

Postdural puncture headache (PDPH) is a recognized complication of unintentional dural puncture during epidural analgesia or intentional dural puncture for spinal anesthesia or for diagnostic or interventional neuraxial procedures. Its incidence varies widely, with rates ranging from less than 2% to 40% depending on procedural and patient factors.^1-3

Postdural puncture headache is usually postural and presents within the first 5 days of witnessed or suspected dural puncture.⁴ Headache is often accompanied by neck stiffness and/or subjective hearing symptoms. Although headache may resolve within 2 weeks, its severity may interfere with daily activities; this severity becomes especially important to postpartum patients caring for a newborn child. Furthermore, PDPH is associated with complications, including chronic headache, backache, cranial nerve dysfunction, subdural hematoma (SDH), and cerebral venous sinus thrombosis (CVST).⁵

Despite numerous reviews on prevention and management of PDPH, most lacked structured recommendations. The reason is that their data were inconclusive, as the studies in these reviews were generally small and heterogeneous, often mixing preventive and therapeutic treatments. In 2013, Bradbury et al⁶ presented evidence on preventive modalities for PDPH. Subsequently in 2019, Russell et al^7,8 summarized evidence on conservative management and use of an epidural blood patch (EBP) for PDPH in obstetrics. More recent studies have been added to the current body of literature.⁹ Furthermore, there is a lack of practice guidelines for both perioperative and diagnostic or interventional settings. The current multisociety practice guidelines we developed aimed to fill this void and provide comprehensive information and patient-centric recommendations for preventing, diagnosing, and managing PDPH.

In accordance with the Common Rule, this Consensus Statement was exempt from institutional review board approval and informed consent because it did not involve human participants or use identifiable data. We followed the Standards for Quality Improvement Reporting Excellence (SQUIRE) reporting guideline.

Two of us (V.U., S.N.), the project cochairs, initially obtained approval from the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) guidelines committee and board of directors. Delegates from the ASRA Pain Medicine, European Society of Regional Anaesthesia and Pain Therapy, Society for Obstetric Anesthesia and Perinatology, Obstetric Anaesthetists’ Association, American Society of Spine Radiology, and American Interventional Headache Society were contacted by the ASRA Pain Medicine executive director and invited to contribute to the development of the present multisociety practice guidelines (Figure). With input from the committee members and stakeholders, the project cochairs developed 10 review questions that we deemed important for the prevention, diagnosis, and management of PDPH. After an initial virtual meeting, collaborators were divided into writing groups, each of which had a designated group leader.

A health sciences librarian conducted literature searches for each question in MEDLINE ALL on March 2, 2022. The search block for the term PDPH that was common to all searches was combined with search blocks that were specific to each review question (eAppendix 1 in the Supplement). Only English-language articles published after 1960 were included. Animal studies were excluded from all searches. Results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. In addition, systematic reviews on PDPH were searched and shared with collaborators, and references were screened to ensure no essential references were missed.

Each group submitted a structured narrative review. Key evidence points were summarized as statements, and practice recommendations were based on the reviewed evidence. Recommendations were evaluated according to the US Preventive Services Task Force guidelines for grading of evidence.¹⁰ Evidence was graded as A, B, C, D, or I (Table 1), whereas the level of certainty was rated as high, moderate, or low (Table 2).¹¹ Statements were presented when recommendations were not possible (eg, for patient factors) or when there was insufficient evidence to make recommendations. Statements were assigned a certainty level without grading, whereas recommendations were assigned both level of certainty and grading. The editing team (including R.R., V.U., and R.S.) reviewed submissions, which underwent multiple iterations with collaborators to formulate an interim draft.

The interim draft was shared electronically, with a request to each collaborator to vote anonymously on each recommendation using a modified Delphi approach.¹² We used Microsoft Excel (Microsoft Corp) for 2 rounds of electronic voting. The Delphi evaluation criteria were simplified, and collaborators were asked to indicate whether they agreed or disagreed with or would like to abstain from each recommendation.¹³ Collaborators were also invited to provide mandatory comments and reasons for their decision if they disagreed or abstained.

The editing team refined and clarified the statements and recommendations after the first round of voting. Recommendations with 100% agreement were accepted, and recommendations with less than 100% agreement were revised with consideration of collaborators’ comments. The aim was to increase the consensus in the second round of voting. In the second round, the statements and recommendations with a predefined agreement greater than 75% were accepted. This threshold was used in another ASRA Pain Medicine consensus guideline.¹⁴ The subsequent draft was shared with all of the collaborators for final approval.

The results retrieved in MEDLINE for each search question are provided in eAppendix 1 in the Supplement. After 2 rounds of anonymous voting by the 21 multidisciplinary collaborators, the predefined consensus was greater than 75% for all statements and recommendations. Specifically, 90% to 100% consensus was obtained for almost all recommendations after the second round of voting (eAppendix 3 in the Supplement). The final draft was approved by each collaborator, the ASRA Pain Medicine board of directors, and the participating societies. The complete references supporting each section are provided in eAppendix 2 in the Supplement. The full narrative synthesis that forms the basis of these recommendations are published elsewhere.¹⁵

According to the 2018 definition by the International Headache Society (IHS), PDPH is a headache attributed to low cerebrospinal fluid (CSF) pressure occurring within 5 days of a lumbar puncture caused by CSF leakage through the dural puncture.¹⁶ Headache is usually accompanied by neck stiffness and/or subjective hearing symptoms, remitting spontaneously within 2 weeks or after sealing of the leak with an autologous epidural lumbar patch. As such, this IHS definition requires evidence of low pressure or CSF leakage on cerebral imaging (showing brain sagging or pachymeningeal enhancement or extradural CSF).

This definition has several potential weaknesses. First, neither opening nor closing pressure has been shown to differ in studies of patients with PDPH compared with controls.^17,18 Second, patients with intracranial hypertension can have PDPH.¹⁹ Third, case reports and series have shown that PDPH may become apparent more than 5 days after dural puncture^20-22 or after hospital discharge.^23,24 Fourth, the omission of the postural component is controversial. The 2013 IHS definition contained a postural component²⁵: “a headache that worsens within 15 minutes after sitting or standing and improves within 15 minutes after lying down after dural puncture has occurred or is suspected.” An analysis of the electronic records of 27 064 parturient individuals with a neuraxial procedure over a 10-year period found that only 8 of 142 parturient individuals with PDPH had no postural component.⁴ Fifth, dural puncture may not be noticed during the procedure.²⁶ Sixth, an increasing body of evidence suggests that headache can persist for longer than 2 weeks.^27-31

In 2021, the American Society of Anesthesiologists released a statement that based the diagnosis of PDPH on both the clinical presentation and a detailed history and physical examination.³² Typical symptoms included neck stiffness; pain in the cervical, thoracic, or lumbar vertebral area; subjective hearing symptoms; visual disturbances; and vertigo. Headaches were frequently reported after childbirth, but only some headaches may be attributed to PDPH.³³

The collaborators generated 37 statements and 47 recommendations after extensively reviewing the current evidence on PDPH. The 10 review questions we developed initially are presented as follows along with final statements and recommendations from the collaborators' working groups.

The statement for this question was, PDPH should be suspected if headache or neurological symptoms, which may be relieved when lying flat, occur within 5 days of a neuraxial procedure (level of certainty: moderate). The recommendation was as follows: inpatients who have received a neuraxial procedure should be reviewed and evaluated for symptoms of PDPH. Outpatients should be instructed to report symptoms of PDPH to their physicians (evidence grade: A; level of certainty: high). Important supporting references were the Headache Classification Committee of the IHS¹⁶ and the American Society of Anesthesiologists.³²

All statements regarding patient factors are provided in Table 3.^34,35 In the statements, younger adults and female sex were associated with an increased risk of PDPH (level of certainty: high).

Statements regarding procedural factors^36-38 are provided in Table 4. There were 4 recommendations for this question. First, routine use of noncutting spinal needles for lumbar puncture for all populations is recommended (evidence grade: A; level of certainty: high). Second, if using a cutting needle for lumbar puncture, the use of a narrower-gauge needle is recommended to reduce the risk of PDPH (evidence grade: A; level of certainty: high).

Third, limited evidence supports the use of narrower-gauge noncutting needles over larger needles for lumbar puncture to reduce the risk of PDPH (evidence grade: C; level of certainty: moderate). Fourth, if using a cutting needle for lumbar puncture, insertion with the bevel parallel to the long axis of the spine is preferred as it may reduce the risk of PDPH (evidence grade: B; level of certainty: moderate).

There were 3 statements for this question. First, after inadvertent dural puncture during attempted epidural catheter insertion, evidence was insufficient to confirm that placement of an intrathecal catheter decreased the risk of PDPH and EBP (level of certainty: low). Second, prophylactic EBPs via an existing epidural catheter or as a stand-alone procedure have been performed following inadvertent dural punctures in both obstetric and non-obstetric populations with variable success. Not every patient who experiences a dural puncture develops a PDPH. Therefore, a policy of routine prophylactic blood patching exposes some patients to unnecessary potential risks. Third, evidence of a reduction in severity of PDPH with prophylactic bed rest was inconclusive (level of certainty: moderate).

There were 5 recommendations for this question. First, after inadvertent dural puncture during epidural catheter placement, an intrathecal catheter may be considered to provide anesthesia or analgesia. This decision must consider the potential risks associated with intrathecal catheters (evidence grade: C; level of certainty: low). Second, a prophylactic EBP is not recommended as routine because there is insufficient evidence to support its effectiveness in preventing PDPH (evidence grade: I; level of certainty: low). Third, bed rest is not routinely recommended as prophylaxis against PDPH (evidence grade: D; level of certainty: moderate). Fourth, routine injection of any substance intrathecally or epidurally to prevent PDPH is not recommended (evidence grade: I; level of certainty: low). Fifth, there is insufficient evidence to recommend routine systemic drug administration for PDPH prophylaxis (evidence grade: I; level of certainty: low). Important supporting references were Bradbury et al,⁶ Heesen et al,³⁹ and Boonmak and Boonmak.⁴⁰

There were 7 recommendations for this question. First, evidence does not support the routine use of bed rest to treat PDPH, although it may be used as a temporizing measure for symptomatic relief (evidence grade: C; level of certainty: low). Second, adequate hydration should be maintained with oral fluids; intravenous fluid should be used when oral hydration cannot be maintained (evidence grade: C; level of certainty: low). Third, evidence does not support the routine use of abdominal binders or aromatherapy to treat PDPH (evidence grade: D; level of certainty: low).

Fourth, regular multimodal analgesia, including acetaminophen and nonsteroidal anti-inflammatory drugs, should be offered to all patients with PDPH unless contraindicated⁴¹ (evidence grade: B; level of certainty: low). Fifth, short-term use of opioids may be considered in the treatment of PDPH if regular multimodal analgesia is ineffective (evidence grade C; level of certainty: low); long-term opioid use is not recommended in the treatment of PDPH (evidence grade: D; level of certainty: moderate).

Sixth, caffeine may be offered in the first 24 hours of symptoms with a maximum dose of 900 mg per day (200-300 mg if breastfeeding) and avoiding multiple sources to prevent adverse effects (evidence grade: B; level of certainty: low). Seventh, evidence does not support the routine use of hydrocortisone, theophylline, triptans, adrenocorticotropic hormone or cosyntropin, neostigmine or atropine, piritramide, methergine, and gabapentin in the management of PDPH (evidence grade: I; level of certainty: low). Important supporting references were Russell et al⁷ and Basurto Ona et al.⁴²

There were 3 statements for this question. First, the efficacy of greater occipital nerve block for PDPH after dural puncture with wider-gauge needles was unclear (level of certainty: low). Second, epidural saline may be of temporary benefit but should not be expected to provide long-lasting relief of PDPH (level of certainty: low). Third, the use of fibrin glue in the treatment of PDPH has been associated with anaphylaxis and aseptic meningitis, although it was not possible to quantify risk (level of certainty: low).

There were 7 recommendations for this question. First, evidence does not support routine use of acupuncture to treat PDPH (evidence grade: I; level of certainty: low). Second, evidence does not support routine use of sphenopalatine ganglion blocks to treat PDPH (evidence grade: I; level of certainty: low). Third, greater occipital nerve blocks may be offered to patients with PDPH after spinal anesthesia with a narrower-gauge (≤22 G) needle, although headache may recur in a substantial proportion of patients, with more severe headache requiring an EBP (evidence grade: C; level of certainty: moderate). Fourth, evidence does not support the use of spinal and epidural morphine to treat PDPH (evidence grade: D; level of certainty: low). Fifth, evidence does not support routine use of epidural dextran, gelatin, or hydroxyethyl starch to treat PDPH (evidence grade: I; level of certainty: low). Sixth, evidence does not support routine use of fibrin glue to treat PDPH (evidence grade: I; level of certainty: low). Seventh, fibrin glue should be reserved for management of PDPH refractory to EBP or when autologous blood injection is contraindicated (evidence grade: I; level of certainty: low). Important supporting references were Russell et al,⁸ Melchart et al,⁴³ Sluder,⁴⁴ Giaccari et al,⁴⁵ and Chang et al.⁴⁶

The statement for this question was that evidence was insufficient to assess the risk-benefit balance for routine cranial imaging before EBP for PDPH (level of certainty: low). There were 2 recommendations for this question. First, brain imaging may be considered when nonorthostatic headache is present or develops after initial orthostatic headache or when headache onset is more than 5 days after suspected dural puncture (evidence grade: C; level of certainty: low). Second, focal neurological deficits, visual changes, alterations in consciousness, or seizures, especially in the postpartum period, should prompt neuroimaging to evaluate alternative diagnoses (evidence grade: B; level of certainty: moderate). Important supporting references were Lee et al⁴⁷ and Chambers et al.⁴⁸

This question had 2 statements. First, the risk of epidural hematoma was low when performing neuraxial procedures in pregnant patients with a platelet count of 70 000 × 10⁶ per liter or greater providing there was no defect in platelet function or other abnormality of coagulation (level of certainty: moderate). Second, there was insufficient evidence for recommending prophylactic antibiotics before EBP (level of certainty: low).

There were 2 recommendations for this question. First, clinicians should follow appropriate guidelines regarding neuraxial injection in patients receiving antithrombotics or patients with low platelet counts (evidence grade: B; level of certainty: moderate). Second, caution should be exercised when considering an EBP in febrile patients or patients presenting with other systemic signs of infection. Deferring the procedure may be appropriate if there is risk of hematogenous infection (evidence grade: C; level of certainty: moderate). Important supporting references were Narouze et al⁴⁹ and Bauer et al.⁵⁰

This question had 6 statements. First, high success rates for EBP that were reported in early studies have not been reproduced in more recent publications, including complete headache remission varying between 33% and 91% (level of certainty: low). Second, optimal EBP volume was unknown and likely varied among patients due to patient factors such as size, age, degree of spondylotic spine changes, and relative size of the dural hole (level of certainty: low). Third, despite the lack of association between EBP volume and success rates, the most recommended volumes were between 15 and 20 mL of blood (level of certainty: low). Fourth, injection of more than 30 mL of blood did not appear to increase the success of EBP (level of certainty: moderate). Fifth, ultrasonography-assisted EBP had the utility for landmark clarification before EBP or for imaging guidance in patients who were unable to receive fluoroscopy or computed tomography (level of certainty: low). Sixth, there was insufficient evidence to recommend a specific duration of immobilization after EBP (level of certainty: low).

There were 14 recommendations for this question. First, when PDPH is refractory to conservative therapy and impairs activities of daily living, an EBP should be considered to treat headache and other neurological sequelae of intracranial hypotension (evidence grade: B; level of certainty: moderate). Second, in patients with PDPH with severe neurological symptoms (eg, hearing loss and cranial neuropathies), EBP should be considered as a therapeutic option (evidence grade: C; level of certainty: moderate). Third, if an EBP is performed within 48 hours of dural puncture, patients should be counseled about a more likely need for repeat EBP to achieve symptom resolution (evidence grade: B; level of certainty: moderate). Fourth, until symptom resolution, regular patient follow-up should be undertaken to determine the need for repeat EBP in cases suggestive of persistent or severe CSF leak (evidence grade: C; level of certainty: low).

Fifth, when the site of dural puncture is known, an EBP should be performed ideally at or 1 space below this level (evidence grade: B; level of certainty: moderate). Sixth, the transforaminal approach to the epidural space with radiologic guidance can be considered in cases of prior laminectomy near the site of dural puncture or after unsuccessful interlaminar EBP (evidence grade: C; level of certainty: moderate). Seventh, the decision to perform EBP under radiologic guidance should be individualized on the basis of patient factors, including age, body mass index, degree of spondylotic change, context of dural puncture, and prior lumbar spine surgery as well as clinician expertise (evidence grade: I; level of certainty: low). Eighth, radiologic guidance should consider risk-benefit analysis, available resources, follow-up capabilities, and where the clinician determines that EBP cannot be safely performed with landmarks alone (evidence grade: I; level of certainty: low). Ninth, strict aseptic technique should be observed in both collection and injection of autologous blood (evidence grade: B; level of certainty: moderate). Tenth, evidence does not support the routine use of blood cultures before an EBP (evidence grade: D; level of certainty: low).

Eleventh, informed consent for an EBP should include the potential for repeat dural puncture, backache, and neurological complications (evidence grade: A; level of certainty: high). Twelfth, to minimize complications, blood should be injected slowly and incrementally. If the patient develops substantial backache or headache (eg, pressure paresthesia), injection of blood should be stopped and resumed based on clinical judgment when symptoms resolve (evidence grade: B; level of certainty: moderate). Thirteenth, after an EBP, if backache persists, increases in severity, or changes in nature, other diagnoses should be investigated (evidence grade: C; level of certainty: low). Fourteenth, epidural analgesia and anesthesia can be effective in patients with a history of EBP and should not be withheld (evidence grade: C; level of certainty: low). Important supporting references were Russell et al⁸ and Boonmak and Boonmak.⁴⁰

Statements for this question were as follows. First, evidence showed an association between inadvertent dural puncture and/or PDPH with chronic headache, backache, neckache, depression, cranial nerve palsy, SDH, or CVST (level of certainty: moderate). Second, evidence was insufficient to determine whether EBP mitigates, prevents, or treats these sequelae (level of certainty: low). Third, PDPH was associated with the development of chronic headache (level of certainty: moderate).

There were 5 recommendations for this question. First, before discharge, information regarding PDPH sequelae should be conveyed to patients, with arrangements for appropriate follow-up and contact information of their anesthesiologist and other health care practitioners (evidence grade: B; level of certainty: moderate). Second, the clinician (or team member) responsible for dural puncture leading to PDPH should ensure that other specialties or primary care physicians are informed of PDPH management and the potential for long-term symptoms (evidence grade: B; level of certainty: moderate).

Third, follow-up with patients who experience PDPH should be continued until headache resolves (evidence grade: B; level of certainty: moderate). Fourth, after discharge from the hospital, follow-up may be continued by the primary care physician. Information regarding PDPH diagnosis and/or inadvertent dural puncture should be communicated to the primary care physician and other specialists, with referrals to a pain or neurology specialist if indicated (evidence grade: C; level of certainty: low). Fifth, urgent neuroimaging and referral to an appropriate specialist should be performed for any patient with PDPH who has worsening symptoms despite an EBP, new focal neurologic symptoms, or a change in the nature of headache (evidence grade: B; level of certainty: moderate). Important supporting references were Mims et al⁵¹ and Barad et al.⁵²

The current practice guidelines we developed provide structured and evidence-based recommendations on pertinent aspects of PDPH, including risk factors, diagnosis, preventive and prophylactic measures, and therapeutic options and their adverse effects. These systematic and evidence-based practice guidelines for PDPH diagnosis and management may reduce morbidity and mortality in patients with PDPH. In addition, they may reduce the economic implications for the health care system and society. The diagnostic criteria for PDPH have changed with subsequent iterations of the IHS guidelines,¹⁶ and while the understanding of the pathophysiological processes and clinical course of PDPH continues to evolve, diagnostic criteria may again change over time.

A crucial aspect of these practice guidelines is identifying risk factors before performing an intentional dural puncture or a procedure that carries the potential risk of unintentional dural puncture to mitigate the risks. The clinician should assess the procedure’s risk-benefit profile and consider whether dural puncture is justifiable. Salient risk factors delineated in these practice guidelines that showed a high level of certainty, such as needle size, type of needle, and patient factors (younger age and female sex), need to be considered before offering neuraxial procedures.

Another vital aspect of these practice guidelines is incorporating an informed consent process for the possibility of PDPH before performing neuraxial procedures. Any center offering lumbar puncture or neuraxial procedures should have a policy on postdischarge follow-up of patients. The policy should include (1) inpatient and outpatient services for identifying and managing PDPH, (2) a plan to diagnose and manage PDPH until resolution, and (3) a pathway to access care to identify and prevent complications of PDPH. Because symptoms of PDPH are similar to other causes of headache, including those associated with intracranial hypertension (such as SDH and CVST), a high index of suspicion should exist when typical features of PDPH are not present or when therapies for PDPH remain ineffective.

There were multiple challenges to developing evidence-based practice guidelines for PDPH, including the wide variety of practice conditions and heterogeneity of the patient population. The evidence review we conducted focused on adult patients, with most of the evidence emanating from publications on anesthesia and lacks patient representation. The review may not have encompassed all clinical scenarios (eg, diagnostic dural punctures, intrathecal chemotherapy, and chronic pain interventions) or special populations (eg, pediatric population or patients with multiple comorbidities). Future studies on the effectiveness of diagnostic and therapeutic options and the prevention of serious complications of PDPH are needed. Investigators may consider novel study methods, such as registry trials and adaptive study designs, as conventional study methods (eg, randomized clinical trials) may be impractical due to low event rates.

Despite advances in evaluation and management of PDPH in the past decades, several recommendations remained of moderate to low certainty because of the source studies’ small sample size, suboptimal design, or, at times, out-of-date evidence. A prime example was the frequent use of caffeine in the management of PDPH, which was based on limited evidence from 2 small randomized clinical trials.^53,54 However, excessive caffeine administration may be associated with adverse effects, such as withdrawal, dehydration, and even seizures. Similarly, 4 randomized clinical trials^55-58 investigated ideal timing for EBP. Their results were conflicting, but overall, there is opportunity for additional trials to improve the evidence on this topic. In obstetric settings, most observational studies suggested that EBP failure (defined as requiring more than 1 EBP) was more likely when EBP was performed within 24 to 48 hours of dural puncture.⁸ Data from observational studies may have selection bias. In patients with severe headaches within 24 hours of the puncture, the dural hole may be large enough to cause a severe CSF leak that requires further intervention (ie, repeat EBP).

Another reason for the moderate to low certainty of evidence was emerging therapies, notably the procedural options for PDPH management. Several interventional techniques, such as greater occipital nerve block or sphenopalatine ganglion blocks, are novel therapies that need more robust evidence. A similar scenario exists with optimal imaging guidance for performance of a blood patch (fluoroscopic guidance vs landmark approach). Furthermore, with the availability of better evidence, our confidence in the certainty of evidence for these recommendations may change.

This consensus statement found that current approaches to the treatment and management of PDPH were not uniform and were hindered by the paucity of evidence. The practice guidelines we developed provide a framework for individual clinicians to assess PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management.

Accepted for Publication: June 1, 2023.

Published: August 15, 2023. doi:10.1001/jamanetworkopen.2023.25387

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Uppal V et al. JAMA Network Open.

Corresponding Author: Vishal Uppal, MBBS, MSc, Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie University, 1276 South Park St, 10W Victoria, Halifax, NS B3H 2Y9, Canada (v.uppal@dal.ca).

Author Contributions: Drs Uppal and Russell had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Uppal, Sondekoppam, Ansari, Baber, Chen, Dîrzu, Kalagara, Kissoon, Leffert, Lim, Lucas, Moka, Sehmbi, Vallejo, Volk, Narouze.

Acquisition, analysis, or interpretation of data: Uppal, Russell, Sondekoppam, Ansari, Baber, Chen, DelPizzo, Dîrzu, Kissoon, Kranz, Leffert, Lim, Lobo, Lucas, Moka, Rodriguez, Sehmbi, Vallejo, Volk, Narouze.

Drafting of the manuscript: Uppal, Russell, Baber, Chen, DelPizzo, Dîrzu, Kalagara, Kissoon, Kranz, Leffert, Lim, Lobo, Lucas, Moka, Rodriguez, Sehmbi, Vallejo, Volk, Narouze.

Critical review of the manuscript for important intellectual content: Uppal, Russell, Sondekoppam, Ansari, Baber, Chen, DelPizzo, Dîrzu, Kalagara, Kissoon, Kranz, Leffert, Lim, Lobo, Lucas, Rodriguez, Vallejo, Volk, Narouze.

Administrative, technical, or material support: Uppal, Sondekoppam, Baber, Chen, Dîrzu, Kissoon, Leffert, Lim, Lobo, Lucas, Sehmbi, Vallejo, Narouze.

Supervision: Narouze.

Conflict of Interest Disclosures: Dr Uppal reported being the associate editor of the Canadian Journal of Anesthesia. Dr Sondekoppam reported receiving personal fees from CIVCO Medical Instruments Co outside the submitted work. Dr Kissoon reported receiving grants from Nevro, royalties from UpToDate, and consulting fees from Bright Minds Biosciences outside the submitted work. Dr Lim reported receiving salary support from the National Institutes of Health Office of Research on Women’s Health, consulting fees from Octapharma, Heron Pharmaceuticals, and for medical expert testimony; grants from Edwards Lifesciences, and royalties from Cambridge University Press outside the submitted work. Dr Volk reported receiving lecture fees from B. Braun Medical and Pajunk outside the submitted work. No other disclosures were reported.

Additional Contributions: Angela Stengel, MS, CAE, American Society of Regional Anesthesia and Pain Medicine, provided project coordination, and Kristy Hancock, MLIS, Maritime Strategy for Patient-Oriented Research Support for People and Patient-Oriented Research and Trials Unit Research Services, assisted with the literature search. These individuals received no additional compensation, outside of their usual salary, for their contributions. The Department of Anesthesia at the Perioperative Medicine and Pain Management of Dalhousie University provided the open access fee for this publication. Editorial assistance from Nascent Medical LLC was funded by ASRA Pain Medicine.