Response: Re: Post-Epidural Headache: How Late Can It Occur?
============================================================

* Brian V. Reamy

*To the Editor:* I want to thank Dr. Quraishi for his comments, insights, and 3 additional literature citations on post-dural puncture headaches (PDPH) by Greene, Quraishi, and Lybecker.1–3 After careful review of these articles, I strongly disagree with his contention that the onset of a PDPH has previously been reported outside the widely accepted range of 1 to 7 days and maintain that the case I described is the first reported instance of a markedly delayed presentation at 12 days post-procedure.4

The fascinating 1961 article by Greene on the neurological sequelae of spinal anesthesia specifically states that, “postspinal headaches will not be considered …” and does not discuss the onset of PDPH in his otherwise thorough review.1 The 2005 commentary by Quraishi cites this same Greene article as the source for the statement that onset of PDPH can be as late as 12 days after dural puncture.2 Finally, the 1995 case series by Lybecker et al specifically reviewed the onset of PDPH in its case series of 873 consecutive patients undergoing 1021 spinal anesthesias that led to 75 episodes of PDPH.3 While he states that the *duration* of headache was from 1 to 12 days, he reports that, “PDPH occurred within 2 days in 96% of the 75 cases included in this study. In all cases the symptoms disappeared spontaneously or because of AEBP within 5 days regardless of the severity of the PDPH.”3 Therefore, in this series *no cases* had *onset* outside a 5-day window, which is well within the traditional 1- to 7-day window reported in the literature.

Dr. Quraishi also raises concerns that the patient's headache could have been worsened by the lumbar puncture done in the Emergency Department (ED). This is certainly a valid point, but it does not mitigate the fact that the onset of the severe headache had already occurred before the ED evaluation. I agree with his feeling that the terms “high” and “spinal” are used in a confusing fashion throughout the literature on PDPH. I applaud Dr. Quraishi's re-emphasis of the key point that individual patient care should not be negatively influenced by the findings of a single pooled analysis.

*Disclaimer:* The views expressed in this reply represent the views of the author and not necessarily those of the United States Air Force, the Uniformed Services University, or the Department of Defense.

## References

1.  Greene NM. Neurological sequelae of spinal anesthesia. Anesthesiology 1961; 22: 682–98.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=13901532&link_type=MED&atom=%2Fjabfp%2F22%2F5%2F592.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A19614197A00010&link_type=ISI) 

2.  Quraishi SA. Abducens palsy following spinal anesthesia: mechanism, treatment, and anesthetic considerations. MedGenMed 2005; 7: 16.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=16369395&link_type=MED&atom=%2Fjabfp%2F22%2F5%2F592.atom) 

3.  Lybecker H, Djernes M, Schmidt JF. Postdural puncture headache (PDPH): onset, duration, severity and associated symptoms. An analysis of 75 consecutive patients with PDPH. Acta Anaesthesiol Scand 1995; 39: 605–12.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=7572008&link_type=MED&atom=%2Fjabfp%2F22%2F5%2F592.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1995RG83900008&link_type=ISI) 

4.  Reamy BV. Post-Epidural Headache: How Late Can it Occur?. J Am Board Fam Med 2009; 22: 202–5.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjIvMi8yMDIiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzIyLzUvNTkyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==)