Post dural puncture headache

Introduction:

Headache is a common finding in parturients following labour and delivery and may be related to multiple causes including dural puncture.(1) Postdural puncture headache is classically defined by the presence of headache worsened by sitting or standing and relieved in the supine position. It may be associated with neckache and less commonly auditory or ocular symptoms.(2) Variations in presentation may occur. Less common but serious conditions may also mimic postdural puncture headache.(3) Any patient with a moderate to severe headache, tinnitus, hearing loss, blurred vision/photophobia or postural headache following spinal or epidural anesthesia should be evaluated by an anesthesiologist.(4) Postdural puncture headache symptoms may require institution of therapy prior to the availability of anesthetic consultation.
Post-dural puncture headache must be distinguished from tension headache, migraine, pre-eclampsia, meningitis, cortical vein thrombosis, intracerebral haemorrhage, subdural haematoma and intracranial tumour. A history of dural puncture may be absent. The headache varies in character but is relieved by lying down and by abdominal compression. Associated symptoms include neckache, nausea, vomiting, photophobia and diplopia. A neglected dural leak may result in convulsions or cranial subdural haematoma, coning and death.

Causes:

CSF Leakage a Probable Cause:PDPH occurs in patients receiving either an epidural or spinal placement, or a therapeutic or diagnostic lumbar puncture involving penetration of the dura mater. Both continuous CSF leakage and pressure on intra-cranial vessels are thought to be involved in the development of PDHD. Removal of CSF from the subarachnoid space results in postural headache which is relieved when saline is administered back into the same space. In addition, patients with PDHD have a lower CSF pressure and volume than controls.
Pressure Causes Pain:A second possible cause of PDPH is pressure on the intracranial vessels relaying pain along the trigeminal, ninth and tenth cranial nerves and sensory nerves to the neck and occiput. Reflex vasodilation caused by pressure on these nerves produces a throbbing pain.

Treatment:

The cause (CSF leakage through a dural hole producing a low CSF pressure) (1), mechanism (traction on the pain sensitive structures in the brain and vasodilation of the cerebral vessels when the patient is upright) (2), and duration (until the hole spontaneously heals and CSF pressure is restored; typically lasts a few days and rarely more than one week) (1) helps to define the condition known as PDPH and to suggest an approach to treatment.
Epidural saline injection:Boluses or infusion of epidural normal saline can help to transiently increase the epidural pressure, slowing the speed at which CSF leaks through the dural hole (3). This may speed the natural healing process. The bolus dose is 30-60 mls given 6 hourly for 4 doses. The rate of infusion is 1000 mls administered over a 24 hour period. Although epidural saline can be a useful technique, higher success rates are often achieved with epidural blood patches.
Caffeine:Caffeine has been suggested as a mode of therapy to help constrict the vasodilated cerebral vessels. It is best administered early in the day so that patients can sleep at night. The dose of caffeine sodium benzoate is 500 mg intravenously which can be repeated once two hours later if the first dose does not have the desired effect (2).
Analgesics:Narcotic analgesics and, in some instances, non-steroidal anti-inflammatory agents are often administered for symptomatic treatment of the headache.
Bedrest:The symptoms of PDPH are alleviated by assuming the horizontal position. Attempts at prophylactic treatment by placing the patient horizontal for a period of time (eg. 24 hours) after a dural puncture have no effect on the incidence or duration of a PDPH; it only delays the onset of the PDPH until the patient ambulates (1). Hydration:Normal hydration of the patient should be maintained. Extra hydration to help the body make more CSF does not alleviate the headache. Dehydration may make symptoms worse.
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