PHARMACOLOGICAL MANAGEMENT OF POSTDURAL PUNCTURE HEADACHE

OBJECTIVE: TO discuss the pathogenesis, incidence, and clinical presen tation of postdural puncture headaches (PDPHs) and to provide a compre hensive evaluation on the pharmacologic management of PDPH. DATA SOURC E: A MEDLINE search was used to identify pertinent literature publishe d in English including review articles, case reports, letters, and abs tracts. Information was also extracted from textbooks for background p urposes. STUDY SELECTION: All clinical studies, case reports, abstract s, and letters were included because of the limited amount of literatu re available on the pharmacologic therapy for PDPH. Related research a rticles and review articles were also used to provide background infor mation on PDPH. DATA EXTRACTION: Methodology and results from clinical trials and abstracts were described and evaluated. Case reports and l etters were summarized and critically reviewed for the feasibility of the different treatment modalities, Information on the pathophysiology , incidence and severity, and clinical presentation of PDPH was extrac ted from related research articles, review articles, and textbooks. DA TA SYNTHESIS: The epidural blood patch (EBP) is one of the most effect ive treatments for PDPH. Pharmacologic management of PDPH offers a les s invasive treatment modality than the EBP. Numerous drug therapies ha ve been presented in the literature, though few merit clinical applica tion. Caffeine therapy, both oral and parenteral, is the most commonly used pharmacologic treatment modality. Theophylline and sumatriptan a re potentially promising agents for the treatment of PDPH. Epidural ad ministration of fluids and drugs is also effective in the treatment of PDPH. Epidural administration of NaCl 0.9% and dextran may be an alte rnative to the EBP when the EBP is unsuccessful or contraindicated. Ep idural adrenocorticotropic hormone and epidural morphine also demonstr ate some potential in the treatment of PDPH. Individual patient charac teristics (i.e., HIV, sepsis) need to be considered when deciding on a treatment. More reports, especially clinical studies, are necessary b efore a definitive statement can be made regarding any one treatment. In the meantime, therapy will be guided by clinical judgment based on the literature reviewed in this article. CONCLUSIONS: Intravenous and oral caffeine are effective and noninvasive treatments for PDPH, Epidu ral NaCl 0.9% or dextran are alternatives when the EBP is unsuccessful or contraindicated, Several methods of pharmacologic management have been cited in the literature, but all require further evaluation.