Management of Post-dural Puncture Headache

黄建宏

Managementof Post-dural Puncture Headache

The International Headache Society has defined PDPH as aheadache that develops within five days of dural puncture. A postdural puncture headache (PDPH) or "spinalheadache" is usually described as a severe, dull, nonthrobbing pain,usually fronto-occipital, which is improveswhen the patient is supine and worsens with sitting upright. It may ormay not be associated with nausea, vomiting, visual disturbances and/orauditory disturbances.

APDPH is usually a self-limiting process. If left untreated, 75% of them willresolve within the first week and 88% will have resolved by 6 weeks (1).

Conservativetreatment

Conservativetreatment includes hydration, bedrest. A systemic review included 23 trials (2477participants). There is no evidence from the study that suggests that routine bed restafter dural punctureis beneficial for the prevention of PDPH onset (2). The role of fluidsupplementation in the prevention of PDPH remains unclear(2). Bedrestis advised simply to reduce the severity of symptoms.

Medicationmanagement:

Fora mild PDPH, NSAIDs are often used. For severe headaches, narcotics can beapplied.

Othermedications included: 500 mg of caffeine sodium benzoate in one liter ofintravenous fluid and infuse this over one hour; 300 mg of oral caffeine; a time-releasepreparation of theophylline; Sumatriptan 6 mg subcutaneously; Cosyntropin 0.25-0.75 mg IV; Gabapentin400 mg eight hourly, spinal fentanyl, rectalindomethacin, intravenous dexamethasone.

A systemic review included10 RCTs (1611 participants) with a majority of women (72%), mostly parturient(women in labor) (913), after a lumbar puncturefor regional anesthesia (3). The study assessed seven medications(epidural and spinal morphine, spinal fentanyl, oral caffeine, rectalindomethacin, intravenous cosyntropin, intravenous aminophylline andintravenous dexamethasone). The results showed that epidural morphine andintravenous cosyntropin proved to be effective at reducing the number ofparticipants affected by PDPH of any severity after lumbar puncture compared toplacebo (3). Aminophylline also reduced the number of participants affected byPDPH of any severity after a lumbar puncture compared to no intervention (3).  The other interventions (fentanyl, caffeine,indomethacin and dexamethasone) did not show conclusive evidence ofeffectiveness (3). There is no strong evidence to support the use of Sumatriptan for PDHA (4). There are no randomized trials to prove the benefit of Gabapentin.

Epiduralblood patch (EBP)

Epidural blood patch is a standard treatment for obstetric patientsexperiencing a severe post-dural puncture headache after medical therapies fail for relief of PDHA. The painrelief from an EBP is often immediate. The common practice is to use 15 to 20ml of blood in the patch(1). With these volumes, the success rates of painrelief are more than 95% of the time (1). There is some evidence that if thepatient remains in the decubitus position for longer periods (1 to 2 hours),the EBP might be more successful (1).

Othersubstances have been used for blood patch: 40 ml of saline, 20 - 30 ml ofdextran, Gelatin powder (Gelfoam) and fibrin glue. There is no strong evidence to support their benefit.

Reference

1.Schwalbe S: Pathophysiology and Management of Post-dural Puncture Headache: ACurrent Review. http://www.soap.org/media/newsle ... logy_management.htm

2. Arevalo-RodriguezI, Ciapponi A,Munoz L,Roqué iFiguls M, Bonfill CospX. Posture and fluids for preventing post-duralpuncture headache. Cochrane Database Syst Rev.2013 Jul 12;7:CD009199

3. Basurto Ona X,Uriona TumaSM, MartínezGarcía L, Solà I,Bonfill CospX. Drug therapy for preventing post-duralpuncture headache. Cochrane Database Syst Rev.2013 Feb 28;2:CD001792

4. Connelly NR, Parker RK, Rahimi A, Gibson CS. Sumatriptan inpatients with postdural puncture headache. Headache 2000; 40:316-9.

黄建宏

欢迎大家翻译成中文！