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Postdural puncture headache
SOHAN PAREKH AND ANDY JAGODA
n Agents
n Caffeine
n Gabapentin
n Epidural blood patch
n Evidence
Postdural puncture headache (PDPH) complicates up to 5% of spinal taps
and is also frequently seen postpartum (from anesthesia-related dural puncture).
The best “treatment” for PDPH is prevention (e.g. use of small-caliber
22- or 24-gauge spinal needles, avoidance of multiple dural penetrations,
replacement of stylet prior to withdrawing needle). Given PDPH’s frequency,
and the usual failure (as shown by meta-analysis) of nondrug interventions
(i.e. bedrest), pharmacotherapy remains an important consideration. 1
Case series data outline some utility of acetaminophen (paracetamol) for
PDPH in postpartum patients. 2 Usually, more potent analgesia is required in
patients presenting to the ED.
Although a variety of approaches to PDPH have been mentioned in reviews,
the drug therapy with the most supporting evidence is caffeine. Oralformulations
of caffeine (300 mg per dose) are more effective than placebo for
PDPH. 3 Intravenous administration of caffeine (250–500mgevery8h) has
been studied in a placebo-controlled fashion, but many of the supporting data
includes co-administration of other drugs. Although the potential confounding
effects of co-administered agents cannot be quantified, there is consistent
indication that IV caffeine is at least partially effective for PDPH. 4
Thrice-daily gabapentin is reported in case series to have efficacy in
PDPH. 5 The evidence is preliminary, but administration of this anticonvulsant
is of potential utility when caffeine fails or is not an option, and patients
are not candidates for (or refuse) epidural blood patch.
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