Thursday May 27, 2010
Post-Dural Puncture Headache (PDPH) -
Part 1 (conservative measures)

After Lumbar Puncture (LP) larger hole in the dura are associated with a greater likelihood of CSF leakage and non-sealage. As CSF leaks out of the subarachnoid space, structures within the cranium(skull) gradually shift downwards. This mechanism stretches sensitive fascial and ligamentous structures, that are attached to cerebral tissue, and dilates cerebral vessels; thus, producing a typical postural headache. Termed "Post-Dural Puncture Headache," (PDPH) it is characterized by headache that dissipates while supine, but reoccurs when upright. Other symptoms include neck stiffness and pain across the upper back. Although the headache itself is harmless, it can be very severe and very debilitating. Most cases of PDPH are short-lived, resolving within 24 hours. However, when persisting for more than 24-36 hours, additional measures are needed. Conservative measures to reduce PDPH includes

1. Bedrest - Since the symptoms of PDPH are alleviated by assuming the horizontal position, keeping a patient horizontal for a period of time (eg. 24 hours) after an intervention is thought to enable spontaneous closure of the dural 'hole.' Unfortunately, it rarely works.

2. Hydration - Extra hydration is thought to facilitate increased CSF production. This, too, rarely works.

3. Analgesics - Narcotic analgesics and, in some instances, non-steroidal anti-inflammatory agents are often administered for symptomatic treatment of the headache. Other agents that have been used include; ACTH, theophylline, vasopressin, and sumatriptan.

4. 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 the patient 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.

5. Epidural saline injection - Boluses or infusions of epidural normal saline can help to transiently increase the epidural pressure; thus, slowing the speed at which CSF leaks through the dural hole. This may facilitate spontaneous closure of the dural 'hole.' The bolus dose is 30-60 mls given every 6 hours for 4 doses. The rate of infusion is 1000 mls administered over a 24 hour period.