From the Guidelines
For a post-lumbar puncture headache that doesn't respond to the first epidural blood patch, a second epidural blood patch should be considered, as this can be effective in treating the headache. The decision to proceed with a second epidural blood patch is supported by the fact that the first attempt may not have been successful due to various factors, including the volume of blood injected or the technique used 1.
Key Considerations for the Second Epidural Blood Patch
- The procedure for the second epidural blood patch is similar to the first, with 15-20 mL of autologous blood injected into the epidural space, as this volume is most commonly recommended and associated with a high success rate 1.
- While waiting for the second procedure, conservative management should continue, including bed rest, hydration, caffeine (300-500 mg daily), and analgesics such as acetaminophen 1000 mg every 6 hours or NSAIDs like ibuprofen 400-600 mg every 6 hours.
- It's also important to note that other treatments like greater occipital nerve blocks may be considered for patients with post-dural puncture headache (PDPH) after spinal anesthesia with a narrower-gauge needle, although the headache may recur in a substantial proportion of patients 1.
Alternative Treatments
If the headache persists after a second blood patch, alternative treatments may be considered, including:
- ACTH/cosyntropin (1 mg IV or IM)
- Gabapentin (300-900 mg daily in divided doses)
- Theophylline (300 mg orally every 6 hours) In rare, severe cases that remain refractory to these measures, consultation with pain management specialists may be necessary to consider more invasive options such as fibrin glue patches or surgical dural repair, although the use of fibrin glue is associated with risks like anaphylaxis and aseptic meningitis and should be reserved for cases refractory to epidural blood patch or when autologous blood injection is contraindicated 1.
From the Research
Treatment Options for Post-LP Headache Unresponsive to First Blood Patch
- If the first epidural blood patch is unsuccessful, several options can be considered for treating post-lumbar puncture (LP) headache:
- Repeat epidural blood patch: Although the study 2 reports a case of delayed radicular pain after two large volume epidural blood patches, it may still be considered as an option.
- Epidural saline infusion: As reported in the study 3, epidural saline infusion can be an effective treatment for post-LP headache after failure of epidural blood patch.
- Epidural dextran 40: The study 4 suggests that epidural dextran 40 can provide relief from post-LP headache in patients who have not responded to other treatments.
Considerations for Treatment
- The choice of treatment should be based on the individual patient's condition and medical history.
- The use of fluoroscopic imaging, as mentioned in the study 2, may be considered to ensure proper needle placement and injectate spread, especially in patients who have failed an initial epidural blood patch.
- The potential complications of epidural blood patch, such as inflammatory response or mechanical compression, should be taken into account when deciding on the treatment plan 2.
Additional Options
- Other treatments, such as bed rest, intravenous hydration, caffeine, and analgesics, may be considered as adjunctive therapies to help manage the patient's symptoms.
- In some cases, as reported in the study 5, an epidural blood patch may be used to treat postdural puncture headache due to other procedures, such as lumboperitoneal shunt placement.