Introduction
Despite advances in equipment and regional anesthetic techniques, postdural puncture headache (PDPH) remains a persistent problem. In many cases, the headache is mild in intensity and brief in duration, without significant sequelae; however, this is not always the case. PDPH is occasionally severe enough to leave patients bedridden and often delays hospital discharge. PDPH can be prolonged, with reports of symptoms lasting months or even years. There is evidence that unintentional dural puncture with a Tuohy needle can lead to the development of chronic headache. Untreated PDPH can lead to the development of persistent cranial nerve palsies and even subdural hematoma. Finally, despite the perception among physicians that PDPH is merely a nuisance, it is a surprisingly frequent, and sometimes a distressingly costly, source of litigation.
A wide range of both conservative and invasive treatments for PDPH has been described in the literature, sometimes with scant scientific support. The rationale for the more common treatments of PDPH in this review are based on our current understanding of the pathophysiology of PDPH. Because there are so few well-controlled studies of the treatment of PDPH, however, many of the treatment recommendations will be based on case reports, observational studies, and personal experience. A century after August Bier first described PDPH, the optimal management of PDPH is a question that remains unanswered.
Pathophysiology
This chapter deals primarily with the treatment of PDPH; however, it should not be forgotten that our main goal should be the prevention of PDPH. As in many other areas of medicine, prevention is far preferable to treatment. There are numerous risk factors for PDPH that cannot be modified, but the two most important can be: needle shape and size. The use of small pencil-point needles for spinal anesthesia (25- or 27-gauge Whitacre, Sprotte, Gertie Marx, or Atraucan needles) will reduce the incidence of headache after dural puncture to 1% or less, even in high-risk populations. If a cutting needle (e.g., Quincke) is used, insertion of the needle with the bevel parallel to the longitudinal axis of the body will significantly decrease the risk of headache. When epidural anesthesia is performed, the option of using such small needles is not possible; we must, instead, rely on meticulous technique. The use of the combined spinal–epidural technique may reduce the risk of accidental dural puncture; the incidence of headache requiring autologous epidural blood patch (EBP) has been reported to be no higher with this technique than with traditional epidural anesthesia.
An understanding of the pathophysiology of PDPH is essential when considering its treatment. There are two competing yet somewhat complementary theories. The first is predicated on the belief that the continued leak of cerebrospinal fluid (CSF) from a dural puncture leads to a loss of fluid from the intracranial compartment. The loss of the cushioning effect of CSF allows the brain to sag within the skull, which places traction on the pain-sensitive meninges, an effect that becomes most apparent in the upright position. This suggests that the treatment of PDPH should be based on minimizing the leak of CSF, increasing CSF production, or translocating CSF from the spinal to the intracranial compartment.
The second theory postulates that the loss of CSF causes intracranial hypotension, which leads to compensatory cerebral vasodilation. This suggests that PDPH is similar to migraine headache, a theory supported both by the similarly increased incidence of migraine and PDPH in women and by MRI studies that demonstrate enhanced cerebral blood flow in PDPH. This theory suggests not only that PDPH will be relieved by restoration of intracranial CSF volume but also that cerebral vasoconstrictors might provide symptomatic relief.
Options
The treatment of PDPH is traditionally divided into conservative and, for want of a better term, aggressive treatment ( Box 54-1 ).
Conservative Treatment
Bed rest
Hydration
Prone position
Abdominal binder
Caffeine (oral or parenteral)
Triptans
Adrenocorticotropic hormone/corticosteroids
Aggressive Treatment
Intrathecal saline injection
Intrathecal catheter
Epidural saline
Epidural morphine
Epidural blood patch
Prophylactic epidural blood patch
Epidural dextran
Evidence
Bed Rest
Bed rest will provide symptomatic relief of PDPH. However, a review of the literature demonstrated that bed rest after dural puncture did not reduce the risk of developing a headache; in fact, the trend was toward increased headache in patients placed at rest. There was no evidence that prolonging the duration of bed rest after dural puncture decreased the likelihood of headache. Early ambulation after dural puncture should be encouraged; patients with an established headache should ambulate as much as they are able to.
Hydration
Despite the widespread enthusiasm for aggressive hydration after dural puncture, only one study of fluid supplementation after dural puncture has been performed ; there was no evidence of any decrease in the incidence of PDPH.
Prone Position
The prone position can relieve headache in some patients with PDPH, but no published studies support this common practice. Presumably, increased intra-abdominal pressure translocates CSF from the lumbar spine to the intracranial compartment. The prone position may be worthwhile in patients whose surgical incision does not preclude this posture.
Abdominal Binder
A single study suggested that an abdominal binder prevents the development of spinal headache. It may provide symptomatic relief by the same mechanism as prone positioning. Again, this may not be feasible in patients with an abdominal incision.
Caffeine (Oral or Parenteral)
A study of 41 patients with headache unresponsive to conservative measures demonstrated that 500 mg intravenous caffeine led to permanent resolution of symptoms in 70% of subjects. The small size of the study and the lack of a control group cast doubt on the routine use of this therapy. Because intravenous caffeine is unavailable in many hospitals, the use of oral caffeine has been proposed as a substitute. Oral caffeine, 300 mg, produced a more significant decrease in headache intensity than placebo ; the effect was short-lived, however, and no reduction was seen in the percentage of patients requiring an EBP.
Sumatriptan
The serotonin agonist sumatriptan is a cerebral vasoconstrictor that is used to treat migraine. One study reported relief of PDPH in four of six patients treated with 6 mg subcutaneous sumatriptan. A subsequent study did not replicate these results, and this treatment should be considered unproved.
Corticosteroids/Adrenocorticotropic Hormone
A number of case reports have suggested a therapeutic role for corticosteroids or adrenocorticotropic hormone (ACTH). A single randomized study demonstrated that high-dose hydrocortisone reduced the severity of spinal headache compared with placebo. A randomized study could not demonstrate any benefit to the administration of ACTH.
Intrathecal Saline
Injection of 10 mL of preservative-free saline via the Tuohy needle after accidental dural puncture decreased the need for EBP from 43% to 5%. Injection of normal saline through an intrathecal catheter placed after accidental dural puncture appeared to decrease the incidence of headache, but the number of patients in this group was too small to achieve statistical significance. When both groups were combined, the incidence of headache after injection of saline through either a catheter or a needle decreased from 62% to 25%.
Intrathecal Catheter
After accidental dural puncture during attempted epidural placement, a catheter can be placed in the subarachnoid space to provide continuous spinal anesthesia. Some studies have suggested that this technique will reduce the incidence of subsequent spinal headache. This result has not been consistently demonstrated, however, perhaps because of differing durations of subarachnoid catheterization in different studies. In fact, one study did show improved results when the catheter remained in place for 24 hours after delivery. If a spinal catheter is placed, it is critical that the sterility of the catheter be maintained. It is also imperative that all anesthetic providers be aware of the subarachnoid location of the catheter so that injection of large (epidural) doses of local anesthetic does not occur.
Epidural Saline
Continuous epidural infusions of normal saline have been reported to prevent or relieve the symptoms of PDPH after accidental dural puncture during epidural placement. Unfortunately, discontinuation of the infusion usually leads to recurrence of the headache. This technique may be useful in patients who refuse an EBP, providing symptomatic relief until the dural puncture spontaneously heals.
Epidural Morphine
A single randomized controlled trial demonstrated that 3 mg epidural morphine administered at the conclusion of anesthesia and the following day decreased the incidence of PDPH from 48% to 12%.
Epidural Blood Patch
The EBP has been proposed as the gold standard for the treatment of PDPH: early reports suggested a success rate (permanent and complete relief of headache) of as high as 95%. Unfortunately, the great majority of these studies were not prospective, and a large meta-analysis suggested that evidence for the efficacy of EBP is lacking. Additionally, some reports suggested that the success rate of EBP may actually be as low as 65%. However, a more recent randomized controlled trial showed that after 7 days, the incidence of headache in patients receiving EBP was reduced to 16% compared with 86% in control subjects; patients in the EBP group with residual headache characterized the severity as mild. EBP is least likely to be successful in patients with larger dural punctures, and these are the very patients in whom headache is most likely to be severe and persistent. In those patients with recurrence of headache after EBP, a repeated procedure is usually successful. Failure of a second EBP should encourage a search for other possible causes of the headache.
The technical aspects of a blood patch increase the likelihood of its success. The spinal interspace chosen for the blood patch should be as close as possible to the initial puncture site, but if the volume of injected blood is sufficient, the spreading of blood in the epidural space is usually extensive enough to reach the dural puncture site from any lumbar interspace. If significant back pain does not develop during injection, a volume of 15 to 20 mL of blood is optimal. The success rate of EBP is improved if the patient is allowed to remain supine for at least 1 hour and possibly as long as 2 hours. The patient should be advised to avoid heavy lifting or straining for at least 48 hours because a forceful Valsalva maneuver may dislodge the patch, which may lead to recurrence of the headache.
The decision to perform an EBP may be influenced by other considerations. The procedure is obviously contraindicated in patients thought to have bacteremia, but a low-grade fever is probably not a contraindication, especially if antibiotic therapy has been initiated. Despite early concerns that central nervous system involvement would be accelerated in human immunodeficiency virus (HIV)-infected patients receiving a blood patch, there is no evidence that this is the case, and EBP is not contraindicated in these patients. Finally, for Jehovah’s Witness patients who refuse EBP for religious reasons, the use of epidural dextran may be an effective alternative, although published experience with this technique is limited, and the patient should be fully informed about the speculative nature of this therapy.
Prophylactic Epidural Blood Patch
EBP administered via an epidural catheter placed subsequent to accidental dural puncture has been reported to decrease the incidence of PDPH by as much as half, from 70% to 30%. More recent work suggests that the usefulness of prophylactic EBP has been significantly overstated, although some evidence has shown that prophylactic EBP may decrease the duration of the headache even if it does not prevent it. Because not all patients will develop PDPH after dural puncture, a substantial number of those who receive a prophylactic EBP will be treated for a complication that may never have developed even in the absence of the treatment. It is therefore essential that patients be fully informed of the potential complications of EBP and that every effort is made to prevent those complications, particularly infection.
Epidural Dextran
In those patients who cannot receive EBP because of a fever or who refuse EBP because of religious reasons, epidural dextran has been used with some success. This modality has never been studied in prospective fashion, and concerns about the potential for neurotoxicity and the risk of allergic reaction remain. Epidural dextran infusions must be considered nonstandard therapy at the present time.
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