How to treat post-dural puncture headache (PDPH) induced by spinal anesthesia?

Treatment of Post-Dural Puncture Headache (PDPH) After Spinal Anesthesia

Begin with multimodal analgesia (acetaminophen and NSAIDs) combined with caffeine in the first 24 hours, maintain adequate oral hydration, and reserve epidural blood patch for cases that fail conservative management within 24-48 hours. 1

Initial Conservative Management (First-Line Treatment)

Analgesia

• Offer regular multimodal analgesia with acetaminophen and NSAIDs to all patients unless contraindicated (evidence grade: B; level of certainty: low). 1, 2
• Prophylactic acetaminophen plus caffeine reduces PDPH risk by 70% and significantly decreases pain intensity when given 2 hours before spinal anesthesia and every 6 hours for 24 hours postoperatively. 3
• Consider short-term opioids only if multimodal analgesia proves ineffective, but limit use to avoid medication overuse headache (evidence grade: C; level of certainty: low). 1, 2, 4

Caffeine Therapy

• Administer caffeine within the first 24 hours of symptom onset with a maximum dose of 900 mg per day (200-300 mg if breastfeeding) to avoid adverse effects from multiple sources (evidence grade: B; level of certainty: low). 1, 2, 4
• Intravenous caffeine sodium benzoate effectively relieves PDPH, though headache may recur and require definitive treatment. 5

Hydration

• Maintain adequate hydration with oral fluids as the primary approach (evidence grade: C; level of certainty: low). 1, 2
• Use intravenous fluids only when oral hydration cannot be maintained. 1, 4

Bed Rest

• Do not routinely recommend bed rest for treating PDPH, though it may be used as a temporizing measure for symptomatic relief while awaiting definitive treatment (evidence grade: C; level of certainty: low). 1, 2

Interventions NOT Recommended

Ineffective Conservative Measures

• Do not use abdominal binders or aromatherapy routinely (evidence grade: D; level of certainty: low). 1

Ineffective Pharmacological Agents

• Avoid routine use of hydrocortisone, teofilina, triptanes, ACTH, cosintropina, neostigmina, atropina, piritramida, metergina, or gabapentina as evidence does not support their effectiveness (evidence grade: I; level of certainty: low). 2

Ineffective Procedural Interventions

• Do not routinely use sphenopalatine ganglion blocks or acupuncture for PDPH treatment (evidence grade: I; level of certainty: low). 2, 6
• Sphenopalatine ganglion blocks are also considered aerosol-generating procedures with infection transmission risks. 6

Procedural Interventions (Second-Line Treatment)

Greater Occipital Nerve Blocks

• Offer bilateral greater occipital nerve blocks to patients who fail conservative management, particularly after spinal anesthesia with narrower gauge needles (22G or smaller) (evidence grade: C; level of certainty: moderate). 1, 2, 4
• This intervention achieved complete pain relief in 68.4% of patients after 1-2 blocks, with significantly lower pain scores and shorter hospital stays compared to conservative therapy alone. 7
• In one study, 33% of patients who failed conservative treatment had symptom resolution with occipital nerve blocks, with significant pain score reduction from 9.73 to 5.55 at 48 hours. 8
• Important caveat: Headache may recur in a substantial proportion of patients, requiring progression to epidural blood patch. 2

Definitive Treatment (Third-Line)

Epidural Blood Patch (EBP)

• Epidural blood patch remains the definitive treatment for PDPH that does not respond to conservative measures (evidence grade: B; level of certainty: high). 1, 2, 4, 6
• Delay EBP until at least 24 hours after dural puncture to increase success rate, but do not delay beyond this in symptomatic patients to minimize suffering. 9
• In patients who failed both conservative treatment and occipital nerve blocks, EBP achieved symptom resolution in 27.78% with significant pain reduction from 9.80 to 3.00. 8
• EBP is invasive and may result in serious complications, so reserve for appropriate cases. 7, 9

Prophylactic EBP

• Do not perform prophylactic epidural blood patch routinely after inadvertent dural puncture, as insufficient evidence supports its effectiveness and it exposes patients to unnecessary risks (evidence grade: I; level of certainty: low). 1

Red Flags Requiring Immediate Neuroimaging

Urgent Evaluation Needed

• Perform neuroimaging immediately if the patient develops focal neurological symptoms, visual changes, altered consciousness, or seizures, especially in the postpartum period (evidence grade: B; level of certainty: moderate). 2, 4
• Consider brain imaging when headache is non-orthostatic or when onset occurs more than 5 days after suspected dural puncture (evidence grade: C; level of certainty: low). 2, 4

Practical Treatment Algorithm

1. Hours 0-24: Multimodal analgesia (acetaminophen + NSAIDs) + caffeine (up to 900 mg/day) + oral hydration
2. If inadequate response at 24-48 hours: Add bilateral greater occipital nerve blocks
3. If persistent symptoms after nerve blocks: Proceed to epidural blood patch (after 24 hours from dural puncture)
4. At any point: If red flag symptoms develop, obtain immediate neuroimaging before proceeding with treatment

This stepwise approach minimizes invasive procedures while providing effective symptom relief, with 38.89% responding to conservative treatment alone, an additional 33.33% responding to nerve blocks, and the remaining cases requiring definitive EBP. 8