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Background and Aims Post-dural puncture headache (PDPH) is a positional headache caused by cerebrospinal fluid (CSF) leakage after dural puncture during spinal anesthesia or inadvertent puncture with an epidural needle. The headache’s mechanism may involve cerebral vasodilation or traction on intracranial structures.

Results A 28-year-old multiparous woman at 38 weeks gestation presented for vaginal delivery with epidural analgesia. Dural puncture epidural analgesia was attempted using an 18-gauge Tuohy needle, during which CSF was noted to flow freely. After administering 2 mg of isobaric bupivacaine and 15 µg fentanyl, the needle was withdrawn and an epidural catheter was placed above the initial site. Labor was managed with hourly 10 ml boluses of 0.0625% bupivacaine, and delivery occurred without complications. Post-delivery, the patient was advised bed rest and IV hydration, with prophylactic administration of an analgesic containing paracetamol and caffeine. The patient developed severe orthostatic headaches and photophobia 60 hours postpartum and returned to the hospital. Treatment included a greater occipital nerve block and trigger point injection under ultrasound guidance, followed by a transnasal sphenopalatine ganglion block. Relief was noted three hours post-treatment. Follow-up telephone assessments at 24 and 48-hours post-discharge recorded no further headaches or additional complaints.

Conclusions For refractory PDPH, a combined greater occipital nerve block and transnasal sphenopalatine ganglion block may be beneficial2,3. This strategy addresses multiple pain pathways potentially contribute to the headache, offering a broader scope of pain relief by modulating both peripheral and central pain pathways.