From the Guidelines
For a post-operative spinal headache persisting for one month, an epidural blood patch (EBP) is the recommended treatment, as it provides immediate relief in 70-90% of cases by sealing the cerebrospinal fluid leak and restoring normal CSF pressure. Before pursuing this invasive option, conservative measures should be tried, including strict bed rest, increased fluid intake (2-3 liters daily), caffeine consumption (300-500 mg daily), and analgesics such as acetaminophen or NSAIDs 1. For medication, caffeine tablets (200 mg every 4-6 hours), acetaminophen (1000 mg every 6 hours), or ibuprofen (400-600 mg every 6 hours) can be used as needed. Some key points to consider in the management of postdural puncture headaches include:
- The use of greater occipital nerve blocks may be offered to patients with PDPH after spinal anesthesia with a narrower-gauge needle, although headache may recur in a substantial proportion of patients 1.
- Evidence does not support the routine use of acupuncture, sphenopalatine ganglion blocks, spinal and epidural morphine, epidural dextran, gelatin, or hydroxyethyl starch, or fibrin glue to treat PDPH 1.
- Fibrin glue should be reserved for management of PDPH refractory to EBP or when autologous blood injection is contraindicated 1. A persistent spinal headache at one month is unusual and warrants evaluation for other causes, including subdural hematoma or meningitis, as noted in the context of imaging for suspected intracranial hypotension 1. The headache occurs because cerebrospinal fluid leakage through the dural puncture reduces the cushioning around the brain, causing traction on pain-sensitive structures when upright.
From the Research
Treatment Options for Postdural Puncture Headache
- Conservative management involving bed rest and pharmacological management is recommended as first-line treatment for mild PDPH 2, 3
- Epidural blood patch (EBP) remains the most effective treatment for moderate-to-severe PDPH, but it is not without inherent risks 2, 3
- Alternative treatments such as epidural saline, dextran 40 mg solutions, hydration, caffeine, sphenopalatine ganglion blocks, and greater occipital nerve blocks have shown promise, but further studies are needed to prove efficacy and safety 2
- Autologous platelet-rich fibrin (PRF) as an alternative epidural patch has shown significant reduction in symptoms and may be a viable solution for patients with persistent PDPH symptoms 4
Pharmacological Management
- Pregabalin and gabapentin have been shown to be useful and safe in the management of PDPH, with pregabalin being more effective 5
- Acetaminophen-caffeine capsule has been compared to intravenous mannitol infusion, with mannitol showing faster and earlier pain reduction 6
- Caffeine has been used for the treatment of PDPH since 1949, and its administration has been shown to be effective in reducing pain scores 6