BACKGROUND To compare the incidence of postural post-dural puncture headache (PPDPH) after spinal anaesthesia using two different 0.40 mm O.D. (27 g) spinal needles: pencil-point needle and Quincke needle. In addition, a meta-analysis of studies comparing small bore spinal needles with regard to development of PPDPH was performed. METHODS Clinical study: A prospective randomised double-blind study was set up to investigate PPDPH after using 0.40 mm pencil-point (Pencan, B. Braun) or Quincke (Spinocan, B. Braun) spinal needle. Postoperatively on day 5 to 7 a telephone interview was conducted in order to reveal postoperative complications such as headache and backache. PPDPH was considered present when the headache was new to the patient, and demonstrated posture dependence. Meta-analysis: Electronic database search and manual search of relevant literature were performed in order to find randomised control trials comparing equal sized (outer diameter, O.D.) spinal needles with different bevel shape. Only studies with a proper method and not merely presented as an abstract were included in addition to the present clinical study. RESULTS Out of 313 patients randomised, 301 were completely followed up, 153 in the pencil-point group and 148 in the Quincke group. The two groups were comparable regarding surgical procedures and demographic data. Of 15 patients suffering from PPDPH, 12 were found in the Quincke group, and 3 in the pencil-point group. The difference was 6.1% (95% CI from 1.2 to 12.5%). The meta-analysis of 1131 patients gave a relative risk of developing PPDPH of 0.38 (95% CI from 0.19 to 0.75) in the pencil-point group compared to the Quincke group. CONCLUSIONS A pencil-point-shaped spinal needle will significantly reduce PPDPH compared with Quincke-type spinal needles, also when small bore needles (0.40 mm O.D.) are used.