Lumbar Puncture and Post-Dural Puncture Headaches: Implications for the Emergency Physician

Robert L. Frank, MD, FAAEM

Disclosures

J Emerg Med. 2008;35(2):149-157. 

In This Article

Treatment of PDPH

Treatment options for dural puncture headache depend on many factors such as severity of headache, degree of interference with activities of daily living, associated symptoms, response to conservative care, and presence of potential contraindications to more definitive therapies. Multiple treatment regimens have been advocated with varying degrees of success and risk, including medications and epidural blood patches ( Table 3 ).

Methylxanthine derivatives such as caffeine and aminophylline have been recommended for the treatment of PDPH. It has been postulated that at least part of the pain from PDPH is due to cerebral vasodilatation as a compensatory attempt to restore intracranial volume.[6] It is thought that methylxanthine medications cause vasoconstriction of these vessels, thus decreasing pain. It has also been theorized that these drugs antagonize purine receptors and relieve headache by this mechanism.[25] Caffeine is usually given as 500-mg caffeine sodium benzoate in 1 L of intravenous fluid over 1 h, although some have given it as a rapid intravenous bolus.[79,80] A second dose usually can be repeated in 1-2 h if needed. If aminophylline is used, it is given 5-6 mg/kg over 20 min or given orally as theophylline 300 mg every 6-8 h.[25] Side effects include central nervous system stimulation, seizures, gastric irritation, and provocation of cardiac dysrhythmias.[80] Methylxanthine medications have been reported to be effective in alleviating PDPH in up to 90% of patients.[79,80,81,82,83,84,85,86] Unfortunately, the data used to support the efficacy of caffeine are limited to one oft-cited small, methodologically flawed study and several case reports.[73,76,77,80,82,84,86,87,88,89] The effects of caffeine seem to be temporary at best, with headache recurrence rates of up to 60%.[9,83,86,89] It has no effect on CSF leakage nor does it restore normal CSF dynamics, which are thought to be the primary causes of PDPH.[5] Camann et al. found oral caffeine to provide significantly better pain relief than placebo for PDPH initially, but there was no significant difference in pain scores at 24 h or in the number of epidural blood patches performed between the two groups.[89] A recent North American hospital survey reports that most practitioners have abandoned the use of caffeine for treatment of PDPH due to its perceived ineffectiveness. Additionally, although it is sometimes recommended that patients consume caffeine after a lumbar puncture to prevent PDPH, it seems that this strategy, too, is ineffective.[90] Further quality investigation is needed to determine the effectiveness of caffeine and theophylline in the prevention and treatment of PDPH.

Sumatriptan is a serotonin agonist occasionally used in the treatment of migraines. It has been reported successful for the treatment of PDPH.[43,91,92] Others have found it to be ineffective.[93] A controlled trial found no evidence of benefit when using sumatriptan in the treatment of PDPH.[94]

Despite a recent Cochrane review that was unable to draw unequivocal conclusions about its efficacy, the epidural blood patch (EBP) is generally considered the definitive treatment for PDPH, especially for those that are severe or debilitating.[5,16,29,43,44,81,95,96,97,98,99] It was first described in 1960 by Gormley after it was noted that "bloody taps" were associated with decreased incidence of PDPH.[100] EBP is performed by injecting 15-30 mL of the patient's blood into the epidural space through a Tuohy epidural needle.[16] This is ideally done at the site of the previous dural puncture. The injected blood spreads in both a cranial and caudal direction. The thecal sac is compressed and displaced and is thought to elevate and thus restore the subarachnoid pressure.[5] It is also thought that the blood clot that forms seals off the rent in the dura and prevents further leakage of CSF. Success rates have generally been reported in 72-98% of patients, although less favorable results have been noted.[1,16,39,81,97,98,101,102,103,104,105] Usually, there is immediate relief of the headache. EBP is most effective when performed at least 24 h after the initial puncture.[25] Complications are rare but include radicular pain from nerve root irritation or displacement, cranial nerve palsies, meningeal irritation, elevated intracranial pressure, paraparesis, cauda equina syndrome, infection, and subdural hematoma.[5,106,107,108] Complications are usually either rare or self-limited. Contraindications to EBP include patient refusal, fever or suspected bacteremia and anticoagulation.[5,108] EBP has been successfully used in adolescents.[48] Patients who get no or incomplete relief after a first EBP have equivalent or higher rates of success on a second attempt.[25,102] Failure of EBP is seen most often in patients with dural puncture from large bore needles, such as with inadvertent dural puncture with 16-gauge Tuohy needles during performance of labor epidural anesthesia.[1,102]

Some practitioners advocate use of a "prophylactic" EBP to prevent PDPH, especially in those at high risk (partiuent with inadvertent dural puncture with a large bore epidural needle). The datasupporting this practice are contradictory. Several studies have shown benefit, others have not.[109,110,111,112] A recent Cochrane review found there were insufficient quality data to reach a definitive conclusion on the effectiveness of this practice.[29] This practice is not likely to have much impact on the prevention of PDPH from diagnostic lumbar punctures performed by emergency physicians.

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