Does conservative management of Post-Dural Puncture Headache (PDPH) include hydration, caffeine, and paracetamol (acetaminophen)?

Conservative Management of Post-Dural Puncture Headache

Yes, hydration, caffeine, and paracetamol (acetaminophen) are all core components of conservative management for Post-Dural Puncture Headache (PDPH). These three interventions form the foundation of initial treatment before considering procedural interventions like epidural blood patch. 1

Evidence-Based Conservative Measures

Hydration

• Adequate hydration should be maintained with oral fluids as a standard conservative measure (evidence grade: C; level of certainty: low). 1
• Intravenous fluids should be used when oral hydration cannot be maintained. 1, 2
• While hydration does not prevent PDPH, maintaining adequate hydration is reasonable supportive care. 2

Paracetamol (Acetaminophen) and NSAIDs

• Regular multimodal analgesia, including acetaminophen and nonsteroidal anti-inflammatory drugs, should be offered to all patients with PDPH unless contraindicated (evidence grade: B; level of certainty: low). 1
• This represents a stronger recommendation than hydration alone, with better evidence quality. 2

Caffeine

• Caffeine may be offered in the first 24 hours of symptoms with a maximum dose of 900 mg per day (200-300 mg if breastfeeding), avoiding multiple sources to prevent adverse effects (evidence grade: B; level of certainty: low). 1
• Caffeine has been shown to decrease the proportion of participants with PDPH persistence and those requiring supplementary interventions when compared with placebo. 3
• Caffeine reduces the number of participants with PDPH at one to two hours compared to placebo. 3

Treatment Algorithm for Conservative Management

First-line approach (within first 24-48 hours):

• Maintain oral hydration 1, 2
• Start multimodal analgesia: acetaminophen + NSAIDs 1, 2
• Offer caffeine (up to 900 mg/day) within first 24 hours 1, 2

If inadequate response:

• Consider short-term opioids (evidence grade: C; level of certainty: low) 1
• Limit opioid use to avoid medication overuse headache 4

Escalation threshold:

• If symptoms are severe or do not begin to resolve after 2-3 days, consider epidural blood patch 2

Important Caveats

What NOT to Do

• Do NOT recommend routine bed rest - evidence does not support its use for treating PDPH, although it may be used as a temporizing measure for symptomatic relief only (evidence grade: C; level of certainty: low). 1, 2
• Do NOT use abdominal binders or aromatherapy - evidence does not support their routine use (evidence grade: D; level of certainty: low). 1

Medications NOT Recommended

• Evidence does not support the routine use of hydrocortisone, theophylline, triptans, adrenocorticotropic hormone, cosyntropin, neostigmine, atropine, piritramide, methergine, or gabapentin in PDPH management (evidence grade: I; level of certainty: low). 1

Red Flags Requiring Immediate Escalation

• Development of neurological focal symptoms, visual changes, altered consciousness, or seizures requires immediate neuroimaging. 2, 4
• Non-orthostatic headache or headache onset more than 5 days after suspected dural puncture warrants brain imaging. 2, 4

Strength of Evidence

The 2023 multisociety consensus guidelines from JAMA Network Open represent the highest quality and most recent evidence available, with recommendations developed through a modified Delphi approach achieving 90-100% consensus among a 21-member multidisciplinary panel. 1 While the certainty of evidence for individual conservative measures ranges from low to moderate, the consistent recommendation across all guidelines supports their use as standard conservative management before proceeding to invasive interventions.