Background: There are two common techniques used in spinal anesthesia, median and paramedian, each of which has advantages and disadvantages. The median approach is the most common technique used, but it is technically difficult. The paramedian approach is sometimes preferred because of faster catheter insertion. The exact mechanisms leading to PDPH are still not completely understood, although several factors, particularly the patient’s age and gender, modulate its incidence. The aim of this work: to assess whichapproach is associated with less frequency of PDPH. Setting: Department of Obstetrics and Gynecology, Al Azhar University. Timing: from the period between July 2012 to May 2014. Study Design: randomized clinical trial Methodolgy:120 pregnant patients had the same characteristics and indicated for cesarean section wereselected to receive spinal anesthesia either by median approach (group1, no. = 60) or para median approach (group2, no =60).Comparison between both groups as regard the incidence of PDPHwithin 2 days after the cesarean section was done. Results: there was a statistically significant difference between the both groups as regard the incidence of PDPH which was more frequent in group1 than group2 (11/56(19.6%) versus 3/58(5.2%) with p=0.018).there were no significant difference between the two groups in view of occurrences of backache, paraethesia or the need for additional analgesia. Conclusion: Para median approach not only associated with significant reduction of PDPH but also with less frequent backache, paraethesia and post-operative need for additional analgesia.