Postdural Puncture Headache In Parturients Research Articles

Comparative evaluation of nebulised dexmedetomidine vs fentanyl for the treatment of post-dural puncture headache (PDPH) in parturients after caesarean section under spinal anaesthesia: A randomised controlled study.

The incidence of post-dural puncture headache (PDPH) following spinal anaesthesia in the obstetric population is around 0.5%-2%. Hydration, bed rest, caffeine, paracetamol, non-steroid anti-inflammatory drugs, epidural blood patches, etc., are the various modalities used for its management. This study aims to compare nebulised dexmedetomidine versus fentanyl for the treatment of PDPH in parturients after caesarean section under spinal anaesthesia. Ninety obstetric patients aged 18-35 years with American Society of Anesthesiologists (ASA) physical status II/III and suffering from PDPH as per the criteria of the International Headache Society after caesarean section under spinal anaesthesia were recruited in this double-blinded randomised study. Patients were randomised to Group D (dexmedetomidine 1 µg/kg nebulisation), Group F (fentanyl 1 µg/kg nebulisation), and Group S (saline nebulisation 4mL). The nebulisation was done 12 hourly for 72 hours. Assessment parameters included pain score and the requirement of additional treatment such as paracetamol, caffeine, and epidural blood patch. Analysis of variance test was used for continuous quantitative variables, and the Kruskal-Wallis test was used for quantitative discrete data. The pain scores at 1, 6, 12, 24, 48, and 72 hours following nebulisation were significantly lower in Group D in comparison to groups F and S (P < 0.001). The number of patients requiring additional analgesic therapy was lower in Group D in comparison to patients in other groups (P < 0.001). Dexmedetomidine nebulisation resulted in effective reduction in PDPH symptoms and pain scores. Nebulisation with fentanyl did not alleviate PDPH symptoms when compared to the control group.

The Effect of Intravenous Infusion of Propofol or Aminophylline on Incidence and Severity of Post-dural Puncture Headache in Elective Cesarean Section

Background: Post-dural puncture headache (PDPH) is caused by the persistent leak of cerebrospinal fluid (CSF) from the subarachnoid space. This leakage causes a decrease in the CSF volume and pressure leading to loss of the cushioning effect normally maintained by the intracranial fluid. This results in traction on the intracranial pain-sensitive structures, causing headache. The aim of the present study was to find ways to reduce the incidence and severity of PDPH in parturients undergoing spinal anesthesia for elective cesarean section. Patients and methods: This was a randomized controlled trial study conducted at Zagazig University Hospitals during the period from February to August 2020. It included 200 parturients, planned for elective caesarean section under spinal anesthesia. All parturients were kept nil orally (8 hrs for fatty meals, 6 hrs for light meals and 2 hrs for clear fluids) before the operation. Ranitidine 50 mg I.M was given to all parturients 90 minutes before the operation. Results: The severity, duration of headache was significantly lower in the propofol group compared with the control and aminophylline groups. There was no significant difference between aminophylline and control groups. Conclusion: We can conclude that propofol reduced the severity, the duration and the associated symptoms of post-dural puncture headache compared to aminophylline in parturients undergoing spinal anesthesia for elective cesarean section.

Effectiveness of nebulized dexmedetomidine for treatment of post-dural puncture headache in parturients undergoing elective cesarean section under spinal anesthesia: a randomized controlled study.

The need for effective treatment for post-dural puncture headache (PDPH) is a growing research entity. This study aimed to test the effectiveness of additional dexmedetomidine (DEX) to PDPH conservative management and evaluate its cerebral hemodynamic effects trans-cranial Doppler. This prospective randomized double-blind controlled trial was conducted on 43 post-partum females suffering from PDPH with visual analog score (VAS) ≥ 4 and Lybecker score ≥ 2. The study subjects were allocated into control group [n = 22] received nebulization of 4 mL 0.9% saline and DEX group [n = 21] received nebulization of 1 µg/kg DEX diluted in 4 mL 0.9% saline twice daily that was continued until achieving VAS score ≤ 3 and Lybecker score < 2 and/or for a maximum of 72 h. Both groups received routine conservative management. The primary outcome was the VAS and Lybecker scores and the secondary results were the DEX effects on cerebral vessels and the occurrence of any adverse effects. VAS and Lybecker scores were significantly lower in DEX group. The middle cerebral artery mean flow velocity was significantly lower, and the pulsatility index was considerably higher after DEX nebulization compared to placebo. Two patients in the control group were indicated for epidural blood patch. The addition of DEX nebulization (1 µg/kg twice daily) to the PDPH conservative care effectively relieved the symptoms and lowered pain scores which could be due to its analgesic and cerebral vasoconstrictive effects. This study was approved by the research ethical committee of Faculty of Medicine, Zagazig University with the reference number (ZU-IRB#: 6075/26-4-2020) and it was registered under clinicaltrials.gov (NCT04327726).

Epidural blood patch in post-dural puncture headache in parturients: A case series

This is a case series of six obstetric patients who had post-dural puncture headache, resistant to conservative treatment. The onset of post-dural headache in our series on average was on the 34th hour of the procedure. After confirmation of the diagnosis with a typical history of presentation and examination, the patients underwent pharmacological treatment. Post-dural puncture headache, in our series, not relieved by pharmacological treatment underwent epidural blood patch after persistent headache in an average of 5 days post-dural puncture. All patients receiving this therapy had a complete cure of headache at the earliest - from 45 minutes to as late as 11 hours post procedure. Epidural autologous blood instillation in an average of 10 to 11 ml completely relieved the ailment in the primary blood patch. Epidural blood patch is still considered gold standard therapy in persistent post-dural puncture headache.

Effect of intrathecal fentanyl on the incidence, severity, and duration of postdural puncture headache in parturients undergoing caesarean section: A randomised controlled trial.

Background and Aims:Postdural puncture headache (PDPH) is a side effect of spinal anaesthesia (SA). This study was conducted to investigate the effect of intrathecal fentanyl on the incidence, severity, and duration of PDPH.Methods:This was a prospective randomised controlled study including 220 parturients, who underwent Caesarean section (CS). They were divided into two groups for administration of SA with bupivacaine (bupivacaine group [B0], n = 111) or bupivacaine with fentanyl (bupivacaine fentanyl group [BF], n = 109). Haemodynamics, quality of anaesthesia, maternal side effects, and postoperative analgesia were noted. The neonatal Apgar score was recorded. The patients were followed up for 14 days after CS for the occurrence of PDPH, and its severity and duration. The collected data were statistically analysed, using the Statistical Package for the Social Sciences software version 25.Results:Regarding haemodynamics, heart rate increased at 5 min post-induction and blood pressure decreased at 2min post-induction in both groups. Excellent intraoperative anaesthesia was obtained in 91.7% and 79.3% of cases in groups BF and B0, respectively (P < 0.01). Longer duration of postoperative analgesia was present in the BF group as compared to the B0 group (P < 0.001). The incidence of PDPH decreased in the BF group in a non-significant manner, whereas its severity and duration increased significantly in the B0 group.Conclusion:Although the addition of intrathecal fentanyl to bupivacaine for SA in CS patients did not reduce the incidence of PDPH significantly, its severity and duration decreased significantly.

Transcranial Doppler role in prediction of post-dural puncture headache in parturients undergoing elective cesarean section: prospective observational study.

Post-dural puncture headache (PDPH) may be resulted from significant changes in cerebral blood flow, which could be visualized by Transcranial Doppler (TCD). This study was performed to investigate if TCD can be used to predict the occurrence of PDPH in high-risk patients. This prospective observational study was conducted on ninety ASA I and II pregnant females undergoing elective cesarean section (CS) under spinal anesthesia. TCD was performed to all patients within 24h before the operation, at 24h and 48h in the post-operative period to measure mean velocity (MV) and Gosling pulsatility index (PI) in the right middle cerebral artery. For 5days postoperatively, all patients were assessed and the PDPH patients were identified, their pre- and post-puncture TCD measurements were compared with the corresponding measurements of PDPH-free patients and ROC analysis was done to evaluate the predictive value of TCD parameters. 17 patients (18.8%) developed PDPH. PDPH group was significantly higher regarding MV and significantly lower with regard to PI at all times except for the pre-spinal PI. The MV values in all patients showed statistical significant increase within the first 48h after CS as compared with those before delivery. In PDPH group there was high statistical significant decrease in PI values at 24h and 48h compared to the pre-puncture values. The pre-puncture MV was the parameter of the best accuracy for predicting PDPH with a cutoff of MV > 68.4cm/s and the post-puncture PI at 24h was the best predictive of PDPH with a cutoff value of < 0.75. TCD might prove a useful tool in predicting PDPH suggesting that higher pre-puncture MV with a cutoff value > 68.4cm/s and post-puncture lower PI at 24h with a cutoff < 0.75 are the best predictive parameters. This clinical trial was registered with ClinicalTrials.gov (NCT03464253).

Effect of Intrathecal Injection Speed on Post-Dural Puncture Headache in Parturients Undergoing Cesarean Section: A Prospective, Randomized Study

Amaç : Bu çalışmada sezaryen geçiren hastalarda intratekal enjeksiyon hızının post-dural ponksiyon baş ağrısı (PDPBA) üzerine etkisinin değerlendirilmesi amaçlanmıştır. Materyal ve Metot: Spinal anestezi ile sezaryen operasyonu planlanan 18-45 yaş arasında 140 hasta randomize olarak 2 gruba ayrılmıştır. Oturur pozisyonda L4-L5 seviyesinden, median girişle, 25G Quincke spinal iğne ile 10 mg hiperbarik 0.5% bupivakaine; Grup I’deki hastalara intratekal enjeksiyon olabildiğince hızlı bir şekilde uygulandı ve Grup II’deki hastalara intratekal enjeksiyon ile 40 sn içinde uygulandı. İntraoperatif dönemde hemodinamik verileri, efedrin kullanımı ve bulantı-kusma sıklığı kaydedildi. İşlem tarihinden 7 gün sonra hastalar telefon ile aranıp PDPBA yönünden sorgulandı. PDPBA’nın sorgulanmasında ICHD-III kriterleri kullanıldı. Bulgular: Gruplar arasında karşılaştırmada PDPBA insidansı (Grup I: %29.0 ve Grup II: %31.4) ve şiddeti açısından anlamlı bir fark bulunamamıştır (p>0.05). Hemodinamik veriler, efedrin kullanımı, bulantı kusma görülme sıklığı karşılaştırıldığında gruplar arasında anlamlı bir fark gözlenmemiştir (p>0.05). Sonuç: Spinal anestezi ile sezaryen geçiren gebelerde, hiperbarik bupivakainin intratekal alana farklı hızlarda verilmesinin; PDPBA sıklığını ve şiddetini, hemodinamik parametreleri, efedrin gereksinimi ve bulantı kusma sıklığını etkilemediği kanaatindeyiz.

Comparison between the Effects of Sumatriptan Versus Naratriptan in the Treatment of Postdural Puncture Headache in Obstetric Patients: A Randomized Controlled Trial.

Background:Postdural puncture headache (PDPH) in the obstetric anesthesia practice is one of the most annoying, common, and important problems.Aim:This comparative study was designed to assess the efficacy of naratriptan in relieving PDPH in parturients who gave birth by cesarean section under intrathecal anesthesia and to compare its efficacy with sumatriptan.Settings and Design:One hundred and eighty-nine adult parturients who complained of PDPH in the first 3 days postpartum period were enrolled in this study. They were divided into three equal parallel groups of 63 each.Materials and Methods:Group-1 controlled (C-group) received multivitamin tablets, Group-2 sumatriptan (S-group) received sumatriptan tablets and Group-3 naratriptan (N-group) received naratriptan tablets. The efficacy of naratriptan in relieving PDPH was studied and compared with that of sumatriptan. Incidences of complications of both drugs were also noted.Statistical Analysis:The collected data were organized, tabulated, and statistically analyzed using SPSS software statistical computer package version 18 (SPSS Inc., USA).Results:After the first 6 h, there were statistically significant differences between Groups S and N from one side and control group from the other side (P < 0.0001 and 0.001), respectively, and the difference between Group S and Group N was statistically significant (P = 0.004). After 12 h, there were statistically significant differences between Groups S and N from one side and the control group from the other side (P < 0.0001) and the difference between Group S and Group N was statistically significant (P = 0.002). After 72 h, there were statistically significant differences between Groups S and N from one side and control group from the other side (P < 0.001 and 0.009), respectively. The difference was nonsignificant between S and N group (P = 0.717).Conclusion:The study revealed that anti-migraine drug naratriptan in combination with supportive treatment was effective in relieving PDPH in parturients.

Incidence of post dural puncture headache in parturients following early ambulation and recumbency

Introductions: Spinal anesthesia is a safe and acceptable technique for patients undergoing caesarean section because it provides both excellent analgesia and muscle relaxation. Post Dural Puncture Headache (PDPH) is frequently reported complication after spinal anesthesia. This study evaluates the incidence of PDPH following early mobilization and recumbency after caesarean section.&#x0D; Methods: This prospective, randomized comparative interventional study included 100 parturients women of age 18 to 45 years, ASA I and II, randomly divided into two groups – Ambulatory ‘A’ and Recumbent ‘R’. At the end of caesarean section, patients were advised to either lie in recumbent position for 24 hours or mobilize as soon as they become ambulatory after spinal aneshthesia. Occurrence of headache were recorded at 24 hours, 72 hours and 7th day. Software SPSS 16, chi-square test was used for proportions like incidence and severity of PDPH; p&lt;0.05 was taken as significant.&#x0D; Results: The incidence of PDPH was statistically not different (p = 0.361) in Group R 8% (4 patients) and in Group A 6% (3 patients). In both the groups, the severity of headache was mild to moderate with only mild headaches in the Group A (p = 0.549).&#x0D; Conclusions: Early ambulation following spinal anesthesia for caesarean section did not increase the incidence of PDPH in parturients.

The Effect of Second-stage Pushing and Body Mass Index on Postdural Puncture Headache

(J Clin Anesth. 2017;37:77–81) The generally accepted mechanism of postdural puncture headache (PDPH) is leakage of cerebrospinal fluid (CSF) from a dural defect, resulting in decreased CSF volume. However, while pushing during the second stage of labor and increased body mass index (BMI) may affect CSF leakage, and thus the incidence of PDPH, studies have reported conflicting results. The authors of the present study explored how pushing during labor and BMI affect the development of PDPH in parturients who experienced dural puncture with a Tuohy epidural needle.

The effect of second-stage pushing and body mass index on postdural puncture headache

Study objectiveTo explore how pushing during labor and body mass index affect the development of postdural puncture headache in parturients who experienced dural puncture with Tuohy needles. DesignRetrospective cohort. SettingObstetric ward and operating rooms at a university-affiliated hospital. PatientsOne hundred ninety parturients who had witnessed dural puncture with 17 or 18 gauge Tuohy needles from 1999-2014. InterventionsPatients were categorized by pushing status and body mass index (kg/m2): nonobese <30, obese 30-39.99, morbidly obese 40-49.99, and super obese ≥50. MeasurementsHeadache, number of days of headache, maximum headache score, and epidural blood patch placement. Main resultsCompared with women who did not push, women who pushed during labor had increased risk of postdural puncture headache (odds ratio [OR], 2.1 [1.1-4.0]; P=.02), more days of headache (P=.02), and increased epidural blood patch placement (P=.02). Super obese patients were less likely to develop headache compared with nonobese (OR, 0.33 [0.13-0.85]; P=.02), obese (OR, 0.37 [0.14-0.98]; P=.045], and morbidly obese patients (OR, 0.20 [0.05-0.68]; P<.01). In a multivariate logistic regression model, lack of pushing (OR, 0.57 [0.29-1.10]; P=.096) and super obesity (OR, 0.41 [0.16-1.02]; P=.056] were no longer significantly associated with reduced risk of postdural puncture headache. ConclusionsParturients who did not push before delivery and parturients with body mass index ≥50kg/m2 were less likely to develop postdural puncture headache in a univariate analysis. Similar trends were demonstrated in a multivariate model, but were no longer statistically significant.

The Relationship of Body Mass Index With the Incidence of Postdural Puncture Headache in Parturients

The Relationship of Body Mass Index With the Incidence of Postdural Puncture Headache in Parturients

Does preoperative gabapentin affects the characteristics of post-dural puncture headache in parturients undergoing cesarean section with spinal anesthesia?

Background:Gabapentin is effective for treating different types of headache including post-dural puncture headache (PDPH), also used for prophylaxis against migraine. We studied the effect of pre-operative administration of gabapentin on the characteristics of PDPH in parturients undergoing cesarean section (CS) under spinal anesthesia.Materials and Methods:Women undergoing elective cesarean section under spinal anesthesia were randomized to receive preoperative gabapentin 600 mg or placebo. Spinal anesthesia was achieved with 12.5 mg hyperbaric bupivacaine plus 25 μg fentanyl. Babies were followed up by Apgar scores, umbilical artery blood gases, breastfeeding difficulties, and need for NICU admission. The mothers were followed up for any side-effects of gabapentin for 24 h. Patients with PDPH were re-admitted and onset and duration of the headache were reported and severity was assessed using a visual analog scale (VAS) for 4 days from diagnosis. Paracetamol with caffeine and diclofenac were given for treatment, and the doses were adjusted according to VAS; also number of doses given for each group was recorded.Results:Eighty eight patients were randomized, and 2 were excluded. The incidence of headache and co-existing symptoms were similar in both groups. The onset of headache was significantly delayed in gabapentin group (P < 0.05). Also, severity and duration of headache were significantly less in gabapentin group (P < 0.05). The incidence of sedation was more in gabapentin group 11 (26.19%) versus placebo group 3 (6.81%). Neonatal outcomes were statistically insignificant between both groups.Conclusion:Pre-operative administration of gabapentin has no effect on incidence of (PDPH) but delays its onset and reduces its severity and duration in parturients undergoing cesarean section with spinal anesthesia without significant adverse effects on the mother or the baby.

Spinal opioids and the prevention of postdural puncture headache

I read with interest the work by Al-metwalli [1] suggesting that epidural morphine reduced the incidence of postdural puncture headache in parturients receiving epidural analgesia. I believe I may have also detected a similar effect from intrathecal diamorphine in preventing postdural puncture headache following spinal anaesthesia. As evidence I would like to report my results from a 9-year prospective audit (1998–2006) of spinal anaesthesia complications in patients undergoing Caesarean section. In our obstetric unit we have a strict follow up policy where all patients receiving spinal anaesthesia are visited by an anaesthetist for a minimum of two postoperative days. One aim of this policy is to monitor the incidence of postdural puncture headache from year to year. From 1998 to 2002 the annual incidence of postdural puncture headache in patients undergoing Caesarean section under spinal anaesthesia was 1–2% but this figure appeared to fall sharply during the period 2003 to 2006. The only significant change in our practice in the latter period was that in late 2002 we introduced the use of intrathecal diamorphine into spinal anaesthesia for caesarean section. The type of spinal needle (25G Whitacre) used in our obstetric unit during the entire audit period remained constant. I presented my results at our department audit meeting and at that time postulated that intrathecal opioids might prevent postdural puncture headache. I then analysed every spinal anaesthetic chart during the 9-year period and divided the Caesarean section population into three groups: 1) no intrathecal opioid administered; 2) intrathecal fentanyl 10–20 μg; 3) intrathecal diamorphine 300 μg. The few cases where a spinal needle different to the 25G Whitacre had been used were excluded. The results are displayed in the table below (Table 1). A total of 5173 patients received spinal anaesthesia for caesarean section during the audit period, of which 4559 were followed up postoperatively. The results appear to suggest that intrathecal diamorphine (but not fentanyl) reduces the incidence of postdural puncture headache after spinal anaesthesia. A previous study also demonstrated that intrathecal fentanyl did not reduce the risk of postdural puncture headache with a 25G Quincke needle [2]. In addition to Al-metwalli’s study there have been other reports of epidural morphine preventing headache after accidental dural puncture [3, 4]. I have however, been unable to find any references to the effect of intrathecal diamorphine on the incidence of postdural puncture headache following spinal anaesthesia. As intrathecal diamorphine is now commonly used in many hospitals in the United Kingdom, I would be interested to hear if anyone else has noticed this additional potential benefit.

The management of accidental dural puncture

I read with interest the recent article by Baraz and Collis [1] discussing the management of accidental dural puncture during labour epidural analgesia in the United Kingdom. The authors are to be congratulated for conducting such an interesting and clinically useful survey of current management of this complication. In my practice of obstetric anaesthesia at the University of California, San Diego, accidental dural puncture is followed by injection of the CSF in the glass syringe back into the subarachnoid space through the epidural needle, insertion of a epidural catheter into the subarachnoid space, injection of a small amount of preservative free saline (3–5 ml) into the subarachnoid space through the intrathecal catheter, administration of a bolus and then continuous subarachnoid labour analgesia, and leaving the catheter in situ in the subarachnoid space for a total of 12–20 h [2, 3]. These five manoeuvers decreased the incidence of epidural needle-induced, postdural puncture headache in parturients following dural puncture with a large bore (for example 18 G) epidural needle from the textbook-referenced 76–85%[4] to 6.6%[3].

Efficacy of a Prophylactic Epidural Blood Patch in Preventing Post-Dural Puncture Headache in Parturients After Inadvertent Dural Puncture

Survey of Anesthesiology: October 2005 - Volume 49 - Issue 5 - p 258-259 doi: 10.1097/01.sa.0000177153.37724.37

Examining the evidence in anesthesia literature: a survey and evaluation of obstetrical postdural puncture headache reports.

To describe a bibliographic database on the literature of postdural puncture headache (PDPH) in the obstetrical population, to describe the research architecture in this field, and to evaluate the quality of case-control studies, cohort studies, and controlled clinical trials on PDPH. Computerized bibliographic searches, citation review, and hand searches were conducted to find all relevant citations on incidence, clinical course, prevention, or treatment of PDPH in parturients. The study design and topic(s) covered by each study were evaluated. Case-control studies and cohort studies were evaluated using the Quality Index; clinical trials were evaluated using the Jadad scale. One hundred ninety-six relevant citations were published between 1949 and 1999. Research on PDPH has been increasing rapidly with the majority of studies published in the 1990's. Incidence and prevention were the focus of over half of all citations. Optimal study designs were infrequently utilized. The methodological quality was poor for observational studies (Quality Index 10/29) and clinical trials (Jadad scale 2/5). Although the amount of research on PDPH in parturients is increasing, use of optimal study designs and improvement in methodology is needed.

Complications with 25-gauge and 27-gauge Whitacre needles during combined spinal-epidural analgesia in labor

Needle size and shape may influence the incidence of paresthesias, post-dural puncture headache and other complications during combined spinal-epidural (CSE) procedures. We have noted a relatively high incidence of transient paresthesias during placement of the spinal needle during CSE for labor analgesia. The purpose of this study was to compare the occurrence of paresthesia and post-dural puncture headache in parturients who received CSE analgesia with either a 25-gauge or 27-gauge Whitacre needle. In a prospective observational study, data were gathered from 478 consecutive women receiving labor analgesia. Incidence, duration, and character of any paresthesias upon spinal needle placement and the incidence and treatment of headache were recorded. The incidence of paresthesia with the two needles was similar (16% with 25-gauge vs15.4% with 27 gauge) but the incidence of post-dural puncture headache was higher with the 25-gauge needle (4% vs 0.7% with 27 gauge, P < 0.05). Our data suggest that with Whitacre needles, 27-gauge might be preferable to 25-gauge needles to reduce the rate of post-dural puncture headache in parturients but that they do not alter the incidence of transient paresthesias.

Complications with 25G and 27G Whitacre Needles During Combined Spinal-Epidural Analgesia in Labor

Needle size and shape may influence the incidence of paresthesias, post-dural puncture headache and other complications during combined spinal-epidural (CSE) procedures. We have noted a relatively high incidence of transient paresthesias during placement of the spinal needle during CSE for labor analgesia. The purpose of this study was to compare the occurrence of paresthesia and post-dural puncture headache in parturients who received CSE analgesia with either a 25-gauge or 27-gauge Whitacre needle. In a prospective observational study, data were gathered from 478 consecutive women receiving labor analgesia. Incidence, duration, and character of any paresthesias upon spinal needle placement and the incidence and treatment of headache were recorded. The incidence of paresthesia with the two needles was similar (16% with 25-gauge vs 15.4% with 27 gauge) but the incidence of post-dural puncture headache was higher with the 25-gauge needle (4% vs 0.7% with 27 gauge, P < 0.05). Our data suggest that with Whitacre needles, 27-gauge might be preferable to 25-gauge needles to reduce the rate of post-dural puncture headache in parturients but that they do not alter the incidence of transient paresthesias.

Role of needle gauge and tip configuration in the production of lumbar puncture headache

Postdural puncture headache (PDPH) is a morbidity that occurs frequently after lumbar puncture. The purpose of this study was to evaluate the role of needle diameter and tip configuration in causing PDPH. The incidence of PDPH was evaluated in parturients because this group of patients is at high risk for developing PDPH and because they often undergo lumbar puncture for spinal anesthesia. The incidence of PDPH after spinal anesthesia with 26- and 27-gauge Quincke and 25-gauge Whitacre needles was studied in a series of 4,125 parturients undergoing spinal anesthesia over a 4-year period. Data were also collected on the incidence of PDPH with 17-gauge Huber-tipped Weiss needles in 21,578 parturients receiving lumbar epidural analgesia and/or anesthesia over the same interval. Additionally, the need to treat PDPH with epidural blood patch in all of these patients was studied. The incidence of PDPH was 5.2% with 26-gauge Quincke needles (1987-1989), 2.7% with 27-gauge Quincke needles (1989-1990), and 1.2% with 25-gauge Whitacre needles (1990-1991). During the same periods, the incidence of PDPH with 17-gauge Weiss needles averaged 1.1%, 1.7% and 1.2%, respectively. As compared with the 26-gauge Quincke needle, there was a lower incidence of PDPH with the 27-gauge Quincke (P < .006) and 25-gauge Whitacre spinal needles (P < .001). The incidence of PDPH with the 25-gauge Whitacre needle was less than that with the 27-gauge Quincke needle (P < .05), and it was similar to the overall rate of headache, which occurs occasionally from accidental dural puncture during the performance of lumbar epidural analgesia/anesthesia for labor and cesarean delivery (P = .974). The need for treating PDPH with epidural blood patching was greatest with the 17-gauge Weiss epidural needle (75.3% of cases), but was similar with the various spinal needles (13-39%). However, because the Whitacre needle produced the fewest PDPHs, it was associated with the lowest absolute requirement for epidural blood patching. The morbidity associated with lumbar puncture can be decreased by selecting the proper needle gauge and tip configuration. Use of the smallest gauge needle and one that has a noncutting Whitacre tip produces the lowest incidence of PDPH in parturients, a group of patients at increased risk for developing PDPH.