What medications are used to treat post dural puncture headache?

Medications for Post Dural Puncture Headache Treatment

The most effective pharmacological treatments for post dural puncture headache (PDPH) include acetaminophen, NSAIDs, and caffeine as first-line agents, with short-term opioids reserved for refractory cases when regular analgesia is ineffective. 1, 2

First-Line Conservative Pharmacological Management

• Adequate hydration should be maintained with oral fluids; intravenous fluids should only be used when oral hydration cannot be maintained 1, 2
• Regular multimodal analgesia with acetaminophen and NSAIDs should be offered to all patients with PDPH unless contraindicated 1
• Caffeine may be offered within the first 24 hours of symptom onset, with a maximum dose of 900 mg per day (200-300 mg if breastfeeding) 1, 2, 3
  • Caffeine administration has shown efficacy in reducing PDPH severity in multiple studies 4
  • The FDA-approved caffeine citrate dosing is equivalent to half the dose when expressed as caffeine base (e.g., 20 mg caffeine citrate = 10 mg caffeine base) 3

Second-Line Pharmacological Options

• Short-term opioids may be considered if regular multimodal analgesia is ineffective 1, 2
  • Caution should be exercised to avoid medication overuse headache with frequent use of opioids (>10 days/month) 2
• Greater occipital nerve blocks (GONB) can be offered as an intermediate pharmacological step before more invasive procedures, particularly after spinal anesthesia with narrower gauge needles 1, 2
  • Studies have shown GONB to be effective in approximately 33% of patients who fail conservative treatment 5

Medications Not Recommended

• Evidence does not support the routine use of hydrocortisone, teofilina, triptans, ACTH or cosintropina, neostigmina or atropina, piritramida, metergina, and gabapentina for PDPH management 1
• These medications have insufficient evidence regarding efficacy and may expose patients to unnecessary risks 1

Definitive Treatment When Medications Fail

• Epidural blood patch (EBP) remains the definitive treatment for cases not responding to pharmacological management, with success rates over 90% 1, 2, 6
• EBP should be considered when conservative pharmacological treatments fail to provide adequate relief 4, 7

Treatment Algorithm

1. Initial Management (First 24-48 hours):

   • Maintain adequate oral hydration 1, 2
   • Administer regular acetaminophen and NSAIDs 1
   • Offer caffeine (up to 900 mg/day) 1, 3

2. If symptoms persist (48-72 hours):

   • Consider short-term opioids for breakthrough pain 1, 2
   • Consider greater occipital nerve blocks 1, 8, 5

3. For refractory cases (>72 hours with significant symptoms):

   • Proceed to epidural blood patch 1, 2, 4, 6

Monitoring Considerations

• Monitor for red flags requiring immediate attention: neurological focal symptoms, visual changes, altered consciousness, or seizures 2
• Consider neuroimaging for non-orthostatic headache or headache onset more than 5 days after suspected dural puncture 1, 2
• Monitor serum caffeine levels when administering caffeine to avoid toxicity (levels >50 mg/L associated with serious toxicity) 3

Prevention Strategies

• Use non-cutting spinal needles rather than cutting needles 9, 1
• Select narrower gauge needles when cutting needles must be used 9, 1
• Position patients in lateral decubitus position during procedures 9, 1, 2