Introduction

Spinal anesthesia is one of the most commonly used regional anesthetic techniques for surgical procedures involving the lower abdomen, pelvis, perineum, and lower extremities. It involves the administration of a single dose of local anesthetic into the intrathecal (subarachnoid) space, producing a reversible sensory, motor, and autonomic blockade below the level of injection. Owing to its rapid onset, reliable anesthetic effect, low cost, and favorable safety profile, spinal anesthesia has become the preferred anesthetic technique for many obstetric and non-obstetric surgical procedures worldwide [1].

The technique was introduced in the late nineteenth century following its accidental discovery by Karl August Bier, who subsequently described both the anesthetic effects and the first documented case of post-dural puncture headache (PDPH) in 1898 [2–4]. Despite considerable advances in spinal needle design and anesthetic practice, PDPH remains one of the most recognized complications of neuraxial anesthesia.

Post-dural puncture headache is defined by the International Classification of Headache Disorders as a headache occurring within five days following dural puncture and caused by cerebrospinal fluid (CSF) leakage through the dural defect [5]. Although PDPH most frequently follows intentional dural puncture during spinal anesthesia or accidental dural puncture during epidural anesthesia, it may also occur after diagnostic lumbar puncture and other neuraxial procedures [5]. Headache is among the most common neurological complaints worldwide and, when associated with neuraxial anesthesia, may substantially impair postoperative recovery, delay hospital discharge, reduce maternal-infant interaction after cesarean delivery, and negatively affect patient satisfaction if not promptly recognized and managed [6].

Pathophysiology of Post-Dural Puncture Headache

The exact pathophysiological mechanisms underlying PDPH remain incompletely understood [7]. The most widely accepted explanation involves persistent leakage of cerebrospinal fluid through the dural puncture site, resulting in reduced CSF volume and intracranial pressure [8]. This reduction causes downward displacement of intracranial structures when the patient assumes an upright position, producing the characteristic orthostatic headache [9]. Consequently, headache typically worsens while sitting or standing and improves within 15–30 minutes of lying supine.

PDPH is frequently accompanied by additional symptoms, including nausea, vomiting, dizziness, neck stiffness, photophobia, phonophobia, tinnitus, diplopia, and shoulder pain [10]. Although symptoms generally resolve spontaneously within several days, a proportion of patients experience prolonged headaches lasting weeks or even months, adversely affecting quality of life and delaying postoperative recovery [11]. The severity of PDPH ranges from mild to severe and commonly involves the frontal, occipital, or generalized regions of the head [12].

Risk Factors and Preventive Strategies

The development of PDPH is influenced by multiple patient- and procedure-related factors. Younger age, female sex, pregnancy, previous history of headache, low body mass index, and connective tissue disorders have all been associated with an increased risk of PDPH [13]. Procedural factors, including the use of larger-gauge spinal needles, cutting (Quincke) needle tips, multiple dural puncture attempts, and operator inexperience, further increase the likelihood of cerebrospinal fluid leakage and subsequent headache [13,14].

The incidence of PDPH reported in the literature varies considerably, ranging from approximately 0.3% to 40%, depending on patient characteristics, needle type and size, anesthetic technique, and diagnostic criteria [15]. Most cases develop within five days after dural puncture, with the highest risk occurring during the first 24–72 hours postoperatively [15].

Adequate hydration is commonly recommended following spinal anesthesia; however, current evidence indicates that excessive fluid administration alone neither prevents nor treats PDPH effectively [16,17]. For persistent or severe cases, an epidural blood patch remains the gold-standard treatment [17].

Several pharmacological and non-pharmacological strategies have been investigated for PDPH prevention and management. Among pharmacological agents, caffeine has received considerable attention because of its ability to antagonize adenosine receptors, induce cerebral vasoconstriction, and potentially increase cerebrospinal fluid production, thereby reducing headache symptoms [18]. Previous studies have suggested that caffeine administration may reduce headache severity and improve analgesic efficacy in patients with PDPH [19]. Other preventive interventions, including perioperative oral magnesium supplementation, have also demonstrated potential benefits in reducing the incidence and severity of PDPH [20]. Furthermore, obesity has been proposed as a protective factor because elevated intra-abdominal pressure may reduce cerebrospinal fluid leakage by increasing epidural pressure; however, evidence supporting this association remains inconsistent [21].

Although numerous studies have investigated the epidemiology and management of PDPH, evidence regarding the influence of routine postoperative coffee consumption remains limited, particularly among mixed obstetric and non-obstetric surgical populations. Therefore, further research is needed to clarify modifiable preventive strategies that may improve postoperative outcomes.

Accordingly, the present study aimed to determine the incidence of post-dural puncture headache among patients undergoing neuraxial anesthesia, identify patient- and procedure-related risk factors associated with its occurrence, and evaluate the effect of postoperative coffee consumption on the development of PDPH.

Materials and Methods

Study Design and Ethical Considerations

This observational case-control study received ethical approval from the Institutional Review Board (IRB) of the College of Nursing and the Research Center Department at the University of Raparin (Approval No. 34; November 25, 2024; Reference No. 2866/28-5-2023). Administrative approval was subsequently obtained from the Presidency of Raparin University and the Raparin Health Directorate (Approval No. 6094; November 12, 2024), followed by authorization from participating hospitals to facilitate data collection. Written informed consent was obtained from all participants before enrollment.

Study Setting and Participants

The study was conducted between December 2, 2024, and April 17, 2025, at Rania Teaching Hospital, the Pediatric and Maternity Teaching Hospital in Rania District, and Peshmarga Health Foundation/Shahid Ahmad Ismail Hospital.

Initially, 192 eligible patients scheduled for spinal anesthesia were screened. Twelve patients were excluded according to the predefined eligibility criteria, resulting in a final sample of 180 participants. The study population included both obstetric and non-obstetric patients, comprising 99 patients undergoing elective general surgery and 81 women undergoing elective cesarean section.

A non-probability purposive sampling technique was used to recruit eligible participants.

Inclusion Criteria

Participants were eligible if they:

• were aged 18 years or older;
• were classified as American Society of Anesthesiologists (ASA) Physical Status I or II [22];
• underwent elective surgery under spinal anesthesia;
• were able to communicate effectively;
• provided written informed consent.

Exclusion Criteria

Patients were excluded if they:

• were younger than 18 years;
• had ASA Physical Status III or higher;
• underwent emergency surgery;
• declined participation;
• were unable to complete postoperative follow-up.

Data Collection and Study Instrument

Data collection was performed between December 2, 2024, and April 17, 2025, using a structured questionnaire developed after an extensive literature review and based on established clinical guidelines and validated assessment instruments, including the 2023 Neuraxial Anesthesia Guidelines [23], the Modified Bromage Motor Block Scale [24], the Clavien–Dindo Classification, the Mankoski Pain Scale, and the Numeric Pain Rating Scale (NPRS) [25].

The questionnaire consisted of three sections.

The first section collected demographic and clinical characteristics, including age, sex, educational level, height, weight, and body mass index (BMI). BMI was calculated as body weight in kilograms divided by height in meters squared (kg/m²).

The second section documented intraoperative variables, including details of the neuraxial anesthesia procedure, spinal needle characteristics, and intraoperative hemodynamic parameters.

The third section assessed postoperative outcomes through telephone follow-up within 24 hours and seven days after surgery. The occurrence, severity, and duration of PDPH and other postoperative complications were documented.

Spinal anesthesia was performed by consultant anesthesiologists under strict aseptic conditions using hyperbaric 0.5% bupivacaine administered through 26- or 27-gauge Quincke spinal needles. Standard intraoperative monitoring and resuscitation equipment were available throughout every procedure, and intravenous access was established before spinal anesthesia.

Validity and Reliability

Content validity was evaluated by fifteen experts in anesthesia, nursing, and related healthcare disciplines between October 1 and November 9, 2024.

A pilot study involving fourteen patients was conducted between November 2 and November 15, 2024. Data from the pilot study were excluded from the final analysis. The instrument demonstrated satisfactory internal consistency, with an overall Cronbach's alpha coefficient of 0.77, indicating acceptable reliability for clinical research.

Statistical Analysis

Statistical analyses were performed using IBM SPSS Statistics version 27.0 (IBM Corp., Armonk, NY, USA). Continuous variables were summarized using means and standard deviations, whereas categorical variables were presented as frequencies and percentages.

The Kolmogorov–Smirnov test was used to assess the normality of continuous variables. Differences between categorical variables were analyzed using the Chi-square test, Fisher's exact test, or the Fisher–Freeman–Halton test, as appropriate. Binary logistic regression analysis was performed to examine factors associated with the occurrence of PDPH [26,27]. Variables with clinical relevance or statistical significance in univariate analyses were subsequently entered into a multivariable logistic regression model to identify independent predictors of PDP

Results

Participant Characteristics

A total of 192 patients were screened for eligibility, of whom 180 met the inclusion criteria and completed the study, while 12 were excluded. The study population consisted of adult patients (18 to >70 years) classified as American Society of Anesthesiologists (ASA) physical status I or II.

Women represented the majority of participants (62.8%), including 50 patients in the control group and 63 in the case group. The mean age was 38.49 ± 15.06 years in the control group and 37.49 ± 13.25 years in the case group. The mean body mass index (BMI) was comparable between groups (30.36 ± 5.04 vs. 30.12 ± 5.67 kg/m²; P = 0.456). Most participants were aged 30–43 years (45.0%), married (82.3%), housewives (52.3%), suburban residents (54.4%), and non-smokers (83.3%). Approximately one-quarter had a previous chronic disease. Conventional spinal anesthesia was the predominant neuraxial technique (70.0%). Previous exposure to spinal anesthesia was reported by 48.3% of participants, whereas only 19.0% had experienced previous spinal anesthesia-related complications. The mean preoperative fasting duration was similar between groups (10.77 ± 1.96 vs. 10.95 ± 1.63 hours).

Sociodemographic Factors Associated with PDPH

Female sex (P = 0.011) and age group (P < 0.001) were significantly associated with the occurrence of post-dural puncture headache (PDPH). In contrast, BMI, educational level, residence, smoking status, history of chronic disease, previous spinal anesthesia, previous spinal anesthesia-related complications, neuraxial anesthesia type, and fasting duration showed no statistically significant association with PDPH (all P > 0.05) (Table 1).

Incidence of Post-Dural Puncture Headache

The incidence of headache varied across the postoperative follow-up period (Table 2). During the intraoperative period, PDPH occurred in 9 patients (5.0%), whereas 10 patients (5.6%) reported headache within the first 24 postoperative hours. By postoperative day 7, the cumulative incidence increased to 70 patients (38.9%).

When analyzed according to study group, intraoperative headache occurred in 4 patients (4.4%) in the control group and 5 patients (5.6%) in the case group. Within 24 hours after surgery, headache was reported by 6 patients (6.7%) and 5 patients (5.6%) in the control and case groups, respectively. At postoperative day 7, PDPH was observed in 40 patients (44.4%) in the control group compared with 30 patients (33.3%) in the coffee-consumption group, representing a statistically significant reduction in headache incidence among patients who consumed coffee (P = 0.003).

Procedural Characteristics Associated with PDPH

Procedural characteristics are presented in Table 3. Most patients in the case group received spinal anesthesia using a 27-gauge Quincke needle (34.4%), whereas 26-gauge needles were more frequently used in the control group (33.9%). However, spinal needle gauge was not significantly associated with PDPH occurrence (P = 0.245).

Similarly, lumbar puncture level, needle insertion angle, number of puncture attempts, patient positioning after spinal anesthesia, anesthesiologist experience, anesthetic dose, systolic blood pressure, diastolic blood pressure, mean arterial pressure, pulse rate, oxygen saturation, and adherence to postoperative oral fluid recommendations were not significantly associated with headache development (all P > 0.05).

Conversely, several procedural factors demonstrated statistically significant associations with PDPH. Patients in the coffee-consumption group received lower intraoperative intravenous fluid volumes (625.56 ± 252.43 mL vs. 696.11 ± 270.89 mL; P < 0.001), lower postoperative intravenous fluid volumes during the first 24 hours (938.89 ± 635.24 mL vs. 1050.00 ± 590.42 mL; P < 0.001), and lower total intravenous fluid administration (1570.00 ± 778.57 mL vs. 1745.56 ± 708.20 mL; P < 0.001). Surgery duration was also significantly shorter in the case group (28.21 ± 12.14 vs. 36.70 ± 36.92 minutes; P < 0.001). Postoperative coffee consumption was significantly associated with a lower incidence of PDPH (P = 0.038).

Obstetric Characteristics

Among the 81 obstetric participants, gravida status demonstrated a significant association with PDPH (P = 0.042). Primigravida women were more likely to develop headache than multiparous women. However, parity, abortion history, previous fetal death, and obstetric versus non-obstetric surgery were not significantly associated with PDPH (all P > 0.05) (Table 4).

Characteristics of Post-Dural Puncture Headache

The clinical characteristics of PDPH are summarized in Table 5. Most headaches developed on the second postoperative day (P < 0.001). The frontal and occipital regions were the most frequently reported headache locations, while headache severity ranged from mild to severe, with significant differences between groups (P < 0.001). The mean headache duration was longer in the control group than in the coffee-consumption group (1.87 ± 2.69 vs. 1.14 ± 2.14 days; P < 0.001).

Headache was predominantly aggravated by physical activity and upright posture, whereas lying supine, rest, analgesic use, and coffee intake were the most commonly reported relieving factors (all P < 0.01). Persistent headache that was difficult to relieve did not differ significantly between groups (P = 0.154).

Common accompanying symptoms included neck stiffness, nausea, vomiting, blurred vision, photophobia, phonophobia, vertigo, dizziness, tinnitus, and shoulder discomfort, all of which were significantly associated with PDPH (most P < 0.001). Neck pain, radicular arm pain, hypoacusis, dysgeusia, and head numbness showed no statistically significant association (all P > 0.05).

Table 1. Baseline demographic and clinical characteristics of the study participants (N = 180)

Values are presented as n (%) unless otherwise indicated. Bold P values indicate statistical significance (P < 0.05).

Table 2. Incidence of post-dural puncture headache during postoperative follow-up

Table 3. Procedural characteristics associated with post-dural puncture headache

Only variables relevant to PDPH are shown.

Table 4. Obstetric characteristics associated with post-dural puncture headache (n = 81)

Table 5. Clinical characteristics of post-dural puncture headache

Discussion

The present study investigated the incidence, associated factors, and preventive effect of postoperative coffee consumption on post-dural puncture headache (PDPH) among patients undergoing neuraxial anesthesia. The findings demonstrated that approximately one-third of participants experienced PDPH during the seven-day follow-up period. Although headache occurred in both study groups, patients who consumed coffee postoperatively experienced a significantly lower incidence, shorter duration, and reduced severity of headache than those in the control group. Most cases developed during the second postoperative day, consistent with the typical clinical course of PDPH.

The timing of headache onset observed in this study agrees with previous investigations reporting that PDPH usually develops within the first five days following dural puncture, with the majority of cases occurring during the initial 24–72 postoperative hours [28]. This temporal pattern is consistent with the pathophysiological mechanism of continuous cerebrospinal fluid (CSF) leakage through the dural puncture site, resulting in intracranial hypotension and orthostatic headache [29].

Female sex and younger age were identified as significant predictors of PDPH. These findings are consistent with previous studies demonstrating that women, particularly those of reproductive age, are at substantially greater risk of developing PDPH than men [30,31]. Several mechanisms have been proposed to explain this association, including hormonal influences on vascular tone, differences in pain perception, connective tissue elasticity, and the high proportion of obstetric patients undergoing cesarean delivery under spinal anesthesia. However, because the present study included more women than men, further studies with balanced sex distributions are needed to better quantify the independent contribution of sex to PDPH risk.

One of the most important findings of the present study was the significant association between postoperative coffee consumption and a lower incidence, reduced severity, and shorter duration of PDPH. Caffeine is a methylxanthine that acts primarily through antagonism of adenosine receptors, resulting in cerebral vasoconstriction and stimulation of cerebrospinal fluid production. These pharmacological effects may partially reverse the cerebral vasodilatation and intracranial hypotension responsible for PDPH symptoms [32]. Our findings support previous clinical studies demonstrating that caffeine is an effective conservative treatment for reducing headache intensity and improving symptom resolution following dural puncture [33,34]. Because coffee is inexpensive, widely available, and generally well tolerated, moderate postoperative coffee intake may represent a practical adjunctive strategy for PDPH prevention, although randomized controlled trials are required to establish optimal dosage and treatment duration.

Hydration has traditionally been recommended as a preventive measure for PDPH; however, the evidence remains controversial. In the present study, adherence to oral fluid intake recommendations was not significantly associated with a reduction in headache incidence. This finding agrees with several systematic reviews reporting insufficient evidence that oral hydration alone prevents PDPH [35]. In contrast, patients receiving larger volumes of intravenous fluids intraoperatively and during the first postoperative 24 hours experienced a lower frequency of headache, suggesting that maintenance of adequate intravascular volume may contribute to improved postoperative recovery. Nevertheless, causality cannot be established because intravenous fluid administration may also reflect differences in perioperative management and patient characteristics. Therefore, prospective randomized studies are needed to clarify the independent role of intravenous fluid therapy in PDPH prevention.

Body mass index was not significantly associated with PDPH in the present study. Although most participants were classified as obese, BMI did not influence headache occurrence despite the theoretical assumption that increased intra-abdominal pressure may reduce CSF leakage by increasing epidural venous pressure. This finding is consistent with previous studies that failed to demonstrate a protective effect of obesity against PDPH [36,37]. Conversely, other investigators have suggested that higher BMI reduces PDPH risk through decreased CSF leakage [21]. These conflicting findings indicate that the relationship between obesity and PDPH remains uncertain and warrants further investigation.

Needle characteristics and procedural variables are recognized determinants of PDPH. In the present study, spinal needle gauge, number of puncture attempts, patient positioning, anesthetic dose, and operator experience were not significantly associated with headache development. These findings differ from previous reports demonstrating that larger needle diameter, multiple puncture attempts, and patient positioning during spinal anesthesia increase the likelihood of PDPH [38,39]. The discrepancy may be explained by the relatively uniform procedural technique employed in the participating hospitals, the predominant use of fine-gauge spinal needles, and the limited number of patients experiencing severe PDPH.

No significant relationship was observed between intraoperative hemodynamic variables and PDPH occurrence. Blood pressure, pulse rate, oxygen saturation, and mean arterial pressure remained comparable between study groups, suggesting that perioperative cardiovascular stability did not influence headache development. This finding supports previous research indicating that hemodynamic changes are unlikely to represent independent predictors of PDPH [34].

Overall, the present study highlights the importance of identifying modifiable preventive factors, particularly postoperative caffeine consumption, while reaffirming the influence of non-modifiable characteristics such as age and sex. These findings contribute to the growing body of evidence supporting conservative preventive strategies aimed at improving postoperative recovery following neuraxial anesthesia.

Conclusion

Post-dural puncture headache remains a relatively common complication during the first postoperative week following neuraxial anesthesia despite the routine use of fine-gauge spinal needles. Female sex and younger age were significant predictors of PDPH, whereas body mass index, spinal needle gauge, and the number of puncture attempts were not independently associated with headache occurrence. Importantly, postoperative coffee consumption was associated with a significantly lower incidence, reduced severity, and shorter duration of PDPH, suggesting that moderate caffeine intake may serve as a simple, inexpensive, and readily available adjunctive preventive strategy. Nevertheless, larger multicenter randomized controlled trials are required to confirm these findings and establish evidence-based recommendations for caffeine administration following neuraxial anesthesia.

Recommendations

Based on the findings of the present study, several recommendations can be made to reduce the incidence and burden of post-dural puncture headache (PDPH) following neuraxial anesthesia. Whenever feasible, clinicians should preferentially use fine-gauge atraumatic spinal needles, as these have been associated with reduced dural injury and cerebrospinal fluid leakage. Comprehensive preoperative and discharge education should also be provided to patients undergoing neuraxial anesthesia, emphasizing the early recognition of PDPH symptoms, appropriate preventive measures, and the importance of seeking timely medical attention if symptoms develop.

Routine postoperative follow-up during the first week after neuraxial anesthesia is recommended to facilitate early identification and management of PDPH. Based on the findings of this study, moderate postoperative coffee or caffeine consumption may be considered as a simple and inexpensive conservative strategy for reducing the incidence, severity, and duration of PDPH in patients without contraindications. However, caffeine intake should remain within established clinical recommendations, and breastfeeding women should limit consumption to approximately 200–300 mg/day, taking into account individual maternal and neonatal health conditions [40].

Given that younger patients and women demonstrated a higher susceptibility to PDPH, preventive interventions and closer postoperative monitoring should be prioritized for these high-risk groups. Finally, further large-scale, multicenter randomized controlled trials are warranted to establish the optimal dose, timing, duration, and safety profile of postoperative caffeine administration and to strengthen the evidence supporting its role in the prevention and management of post-dural puncture headache.

Abbreviation

ASA - American Society of Anesthesiologists

BMI - Body mass index

C/S   - Cesarean Section

CSF - Cerebrospinal Fluid

LP – Lumber Puncture

PDPH - post-dural puncture Headache

PSPH – Post Spinal Puncture Headache

SA     - Spinal Anesthesia

NA   - Neuraxial Anesthesia

Conflict of interest

All authors declare no conflict of interest.

Acknowledgments: We would like to appreciate all supports provided by University of Raparin, Rania Teaching Hospital, Pediatric and Maternity Teaching Hospital in Rania District, and Peshmarga Health Foundation/ Shahid Ahmad Ismail’s Hospital during the data collection process.