What is the treatment for postdural puncture headache?

Treatment of Postdural Puncture Headache

Begin with conservative management including multimodal analgesia (acetaminophen and NSAIDs) and caffeine within the first 24 hours, reserving epidural blood patch for moderate-to-severe cases or those failing conservative measures. 1

Initial Conservative Management

Hydration

• Maintain adequate hydration with oral fluids as the primary approach 1, 2
• Use intravenous fluids only when oral hydration cannot be maintained 1, 2
• Note that hyperhydration is no longer recommended and provides no additional benefit 3

Multimodal Analgesia (First-Line)

• Offer regular multimodal analgesia with acetaminophen and NSAIDs to all patients unless contraindicated (evidence grade B, low certainty) 1, 2
• This should be the foundation of initial pain management 2, 4

Caffeine (Early Intervention)

• Offer caffeine within the first 24 hours of symptom onset with a maximum dose of 900 mg per day (evidence grade B, low certainty) 2, 4
• If breastfeeding, limit to 200-300 mg per day 2, 4
• Avoid multiple caffeine sources to prevent adverse effects 2
• Caffeine has been shown to reduce the proportion of patients with persistent PDPH and decrease the need for supplementary interventions 5

Opioids (If Needed)

• Consider short-term opioid use only if regular multimodal analgesia is ineffective (evidence grade C, low certainty) 2, 4
• Limit use to avoid medication overuse headache 4

Bed Rest (Not Routinely Recommended)

• Bed rest is NOT routinely recommended for treating PDPH (evidence grade C, low certainty) 1
• May be used only as a temporizing measure for symptomatic relief 1, 2
• Strict bed rest is no longer considered effective based on current evidence 3

Interventions NOT Recommended

The following pharmacological agents lack sufficient evidence and should NOT be used routinely for PDPH management:

• Hydrocortisone, teofilina, triptanes (including sumatriptan), ACTH, cosintropina, neostigmina, atropina, piritramida, metergina, and gabapentina (evidence grade I, low certainty) 2
• Abdominal binders and aromatherapy are also not supported by evidence 1

Procedural Interventions

Greater Occipital Nerve Blocks (Intermediate Option)

• May be offered to patients with PDPH after spinal anesthesia with narrower gauge needles (evidence grade C, moderate certainty) 2, 4
• This is particularly useful as an intermediate step before proceeding to epidural blood patch 4, 6
• Studies show 33-68% of patients achieve complete pain relief with 1-4 blocks 7, 8
• Important caveat: headache may recur in a substantial proportion of patients, requiring epidural blood patch 2
• Bilateral greater occipital nerve blocks result in significantly lower pain scores, reduced analgesic consumption, and shorter hospital stays compared to conservative treatment alone 7

Epidural Blood Patch (Definitive Treatment)

• Epidural blood patch remains the definitive treatment for moderate-to-severe PDPH or cases not responding to conservative measures 2, 4, 6
• This is the most effective treatment with high success rates 3
• Should be performed when conservative management fails 6, 8

NOT Recommended Procedural Interventions

• Acupuncture and sphenopalatine ganglion blocks are not recommended for routine use (evidence grade I, low certainty) 2

Red Flags Requiring Immediate Neuroimaging

Perform neuroimaging urgently if any of the following develop (evidence grade B, moderate certainty):

• Focal neurological symptoms 2, 4
• Visual changes 2, 4
• Altered consciousness 2, 4
• Seizures, especially in the postpartum period 2, 4

Consider brain imaging when (evidence grade C, low certainty):

• Headache is non-orthostatic in nature 2, 4
• Headache onset occurs more than 5 days after suspected dural puncture 2, 4

Treatment Algorithm

1. Start immediately with: Multimodal analgesia (acetaminophen + NSAIDs) + caffeine (within 24 hours) + adequate oral hydration 1, 2

2. If inadequate response: Add short-term opioids 2, 4

3. If still inadequate response: Consider bilateral greater occipital nerve blocks 2, 4, 7

4. If moderate-to-severe PDPH or failure of above measures: Proceed to epidural blood patch 2, 4, 6

5. Throughout treatment: Monitor for red flag symptoms requiring neuroimaging 2, 4

Important Clinical Pitfalls

• Do not prescribe routine bed rest—it is ineffective and delays recovery 1, 3
• Do not use prophylactic epidural blood patch routinely, as not all patients develop PDPH and this exposes them to unnecessary risks 1
• Avoid medication overuse by limiting acute headache therapy to no more than twice weekly 4
• Do not delay epidural blood patch in moderate-to-severe cases while trying multiple ineffective conservative measures 6