Lumbar puncture headache in relation to sex, age, and cerebrospinal fluid findings.

Post-lumbar puncture headaches are recognized as being a hazard in the diagnosis and management of patients suffering from syphilis. Much work has been done in the past, and is still being done, to reduce their incidence. There are certain factors which have a definite influence in reducing the number of headaches after lumbar puncture, the most important being the skill of the operator. Allen (1934) reported a 545 per cent. headache rate after failure of the puncture, and only 15 5 per cent. when successful, while the figures of Erskine and Johnson (1938) were 891 per cent. and 3-4 per cent. respectively. The use of a fine-gauge needle similarly reduces the incidence: Redlich, Moore, and Kimbell (1946), using 16and 22-gauge needles, recorded 60 per cent. and 48 per cent. headaches respectively, and Emory (1948) observed headaches in 41 8 per cent. of patients when a 19-gauge needle was used, the incidence dropping to 275 per cent. with a 20-gauge needle. If the cerebrospinal fluid is abnormal, there is less chance of headache after lumbar puncture; Nelson (1930) recorded 21 8 per cent. headaches with normal and 10 per cent. with pathological fluids. Several other authors, including Allen (1934) and Erskine and Johnson (1938), have reported similar findings, the only contradictory ones being in a small series by Grewel (1936). The position of the patient during lumbar puncture would appear to play a part in the incidence-of headaches, those lying in the left lateral position having fewer headaches than those sitting up. This was observed by Underwood (1946), whose incidence for lying and sitting up was 17 per cent. and 22 per cent. respectively, and Emory (1948), whose figures were 268 per cent. and 41 8 per cent. Other measures of doubtful value include the use of drugs, Baar (1920) giving intravenous saline after lumbar puncture and Emory (1948) giving 2 g. salt (NaCI) immediately before, and Stiurup (1933) inserting an atropine suppository after lumbar puncture. Rest would not appear to be of any help in lowering the incidence of headaches, according to the findings of Blau (1941), Underwood (1946), and Emory (1948), who found that the longer the rest, the greater the number of headaches. Recently, however, Rosedale (1956), reporting a personal series of 449 lumbar punctures, had a headache rate in male patients under the age of 40 years of 3 2 per cent. with 18 hours of rest, as compared with 265 per cent. without rest. Quasi-surgical procedures, such as plugging the wound with cat-gut, as recommended by Nelson (1930) and Emory (1948), are not practical in out-patient clinics. Dattner (1944) states that headache can be prevented by rest in bed, but only for the time that the patient is lying prone. The incidence can be reduced by the use of fine or double needles, but even then some patients will have postpunctural disturbances even though all precautions are taken. Any theory as to the causation of these headaches must take into consideration the following points: