SAN DIEGO—Physicians may want to reconsider their routine practice of recommending bed rest to prevent headaches after a dural puncture, investigators said at the 52nd Annual Meeting of the American Academy of Neurology. Syed Rizvi, MD, and colleagues at the University Hospital and Medical Center in Stony Brook, New York, found that bed rest did not reduce the frequency of postdural puncture headache (PDPH). Bed rest did, however, tend to lessen the severity of such headaches.

FREQUENCY VERSUS SEVERITY

Their findings are based on observations in 170 consecutive patients who underwent a lumbar puncture as part of an evaluation for suspected Lyme disease or multiple sclerosis; all procedures were performed by the same neurologist. Overall, 110 patients were mobilized immediately, and 60 patients underwent a 30 minute bed rest.

Of 153 patients who completed the study, 36 (23.5%) developed a headache. In 15 (9.8%) cases, the headache was moderate or severe, and only three (1.9%) required aggressive treatment (blood patch or intravenous caffeine) for their symptoms. Patients who were mobilized immediately and patients who underwent brief bed rest had a similar headache frequency (25% versus 21% for the two groups, respectively). Moderate to severe headaches were significantly more common in patients who were mobilized immediately than in patients who had a brief period of bed rest (86.6% versus 13.4%).

Prior research has shown that those individuals most likely to develop PDPH are those with a history of headaches, female patients, younger patients, patients with a low body mass index, anxious patients, and patients undergoing neurologic procedures. Higher-gauge needles and atraumatic needles are associated with the lowest incidence of PDPH, Dr. Rizvi noted. The number of puncture attempts, the quantity of cerebrospinal fluid removed, the qualifications of the operator, the orientation of the needle, and duration of the procedure have been found to have no effect on the development of a headache, he added.

UNNECESSARY AND IMPRACTICAL?

"Patients are typically asked to lie down for several hours—usually for four to six hours in the office and then for as long as 24 to 48 hours at home—with the goal of preventing a headache," commented Dr. Rizvi, who is an Assistant Professor of Neurology. "Patients are often bored while lying there doing nothing, and this practice consumes a lot of office space."

Since the overall incidence of significant PDPH is very low and it occurs as often in patients who are mobilized immediately as in patients who have a short period of bed rest, prophylactic bed rest should be reserved for young women who are at highest risk of severe headaches, Dr. Rizvi advised. And there is no additional benefit if patients rest for more than 30 minutes.

—Jill Stein

Suggested Reading
Kuntz KM, Kokmen E, Stevens JC, et al. Post-lumbar puncture headaches: experience in 501 consecutive procedures. Neurology. 1992;42:1884-1887.
Lambert DH, Hurley RJ, Hertwig L, Datta S. Role of needle gauge and tip configuration in the production of lumbar puncture headache. Reg Anesth. 1997;22:66-72.

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