Drug therapy for preventing post-dural puncture headache

Emergency Department, Hospital de Figueres, Fundació Salut Empordà, Rda Rector Aroles s/n, Figueres, Girona-Catalunya, Spain, 17600.
Cochrane database of systematic reviews (Online) (Impact Factor: 5.94). 01/2013; 2(2):CD001792. DOI: 10.1002/14651858.CD001792.pub3
Source: PubMed

ABSTRACT Post-dural (post-lumbar or post-spinal) puncture headache (PDPH) is one of the most common complications of diagnostic, therapeutic or inadvertent lumbar punctures. Many drug options have been used to prevent headache in clinical practice and have also been tested in some clinical studies, but there are still some uncertainties about their clinical effectiveness.
To assess the effectiveness and safety of drugs for preventing PDPH in adults and children.
The search strategy included the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2012, Issue 5), MEDLINE (from 1950 to May 2012), EMBASE (from 1980 to May 2012) and CINAHL (from 1982 to June 2012). There was no language restriction.
We considered randomised controlled trials (RCTs) that assessed the effectiveness of any drug used for preventing PDPH.
Review authors independently selected studies, assessed risks of bias and extracted data. We estimated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous outcomes. We calculated a 95% confidence interval (CI) for each RR and MD. We did not undertake meta-analysis because participants' characteristics or assessed doses of drugs were too different in the included studies. We performed an intention-to-treat (ITT) analysis.
We included 10 RCTs (1611 participants) in this review with a majority of women (72%), mostly parturients (women in labour) (913), after a lumbar puncture for regional anaesthesia. Drugs assessed were epidural and spinal morphine, spinal fentanyl, oral caffeine, rectal indomethacin, intravenous cosyntropin, intravenous aminophylline and intravenous dexamethasone.All the included RCTs reported data on the primary outcome, i.e. the number of participants affected by PDPH of any severity after a lumbar puncture. Epidural morphine and intravenous cosyntropin reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to placebo. Also, intravenous aminophylline reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to no intervention, while intravenous dexamethasone increased it. Spinal morphine increased the number of participants affected by pruritus when compared to placebo, and epidural morphine increased the number of participants affected by nausea and vomiting when compared to placebo. Oral caffeine increased the number of participants affected by insomnia when compared to placebo.The remainder of the interventions analysed did not show any relevant effect for any of the outcomes.None of the included RCTs reported the number of days that patients stayed in hospital.
Morphine and cosyntropin have shown effectiveness for reducing the number of participants affected by PDPH of any severity after a lumbar puncture, when compared to placebo, especially in patients with high risk of PDPH, such as obstetric patients who have had an inadvertent dural puncture. Aminophylline also reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to no intervention in patients undergoing elective caesarean section. Dexamethasone increased the risk of PDPH, after spinal anaesthesia for caesarean section, when compared to placebo. Morphine also increased the number of participants affected by adverse events (pruritus and nausea and vomiting)There is a lack of conclusive evidence for the other drugs assessed (fentanyl, caffeine, indomethacin and dexamethasone).These conclusions should be interpreted with caution, owing to the lack of information, to allow correct appraisal of risk of bias and the small sample sizes of studies.

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    ABSTRACT: Ever since the first spinal anesthetic in the late 19th century, the problem of “spinal headache” or post-dural puncture headache (PDPH) has plagued clinicians, and more importantly, patients. It has long been realized that the headache and other symptoms that often occur after the entry of a needle into the subarachnoid space is somehow related to fluid loss, although the exact pathophysiology of the headache has really never been defined. With the introduction of pencil-point spinal needles for spinal anesthesia in pregnant women over the past 2 decades, the problem of PDPH in obstetrics has been more associated with accidental dural puncture during attempted epidural procedures. Accidental puncture probably occurs in about 1% of procedures, so with over 60% of pregnant women receiving epidural analgesia for labor, there are probably 20,000–50,000 obstetric patients with PDPH in the United States each year. In this article, we will discuss the current state of knowledge in this area, suggesting that the PDPH syndrome is more severe and often more long-lasting, with some potentially life-threatening complications (cerebral hemorrhage) than usually appreciated or admitted. While prevention and treatment options are still limited, with the only clearly effective treatment being the epidural blood patch, recognition of the PDPH syndrome in postpartum women by anesthesiologists and obstetricians, with aggressive follow-up and treatment, may help limit the associated morbidity and mortality.
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