Management Of Postdural Puncture Headache Research Articles

Efficacy of therapies for post dural puncture headache.

Clinical management of postdural puncture headache (PDPH) remains an interdisciplinary challenge with significant impact on both morbidity and quality of life. This review aims to give an overview of the most recent literature on prophylactic and therapeutic measures and to discuss novel findings with regard to currently published consensus practice guideline recommendations. Although current evidence does not support a recommendation of any specific prophylactic measure, new data is available on the use of intrathecal catheters to prevent PDPH and/or to avoid invasive procedures. In case of disabling or refractory symptoms despite conservative treatments, the epidural blood patch (EBP) remains the therapeutic gold standard and its use should not be delayed in the absence of contraindications. However, recent clinical studies and meta-analyses provide additional findings on the therapeutic use of local anesthetics as potential noninvasive alternatives for early symptom control. There is continuing research focusing on both prophylactic and therapeutic measures offering promising data on potential alternatives to invasive procedures, although there is currently no treatment option that comes close to the effectiveness of an EBP. A better understanding of PDPH pathophysiology is not only necessary to identify new therapeutic targets, but also to recognize patients who benefit most from current treatments, as this might enhance their therapeutic efficacy.

Incidence and Management of Post-dural Puncture Headache among Parturients: A Retrospective Analysis

Background: Postdural puncture headache (PDPH) is a known complication following spinal and epidural anesthesia. Study Design: This is a retrospective study to assess the incidence, risk factors, severity, and management of PDPH. Materials: The data were extracted from the medical records. All parturients who gave birth under spinal anesthesia or epidural analgesia were included. Maternal demographics, the size of the needle, the position of the parturient, and the day of onset of the headache were noted. Categorical variables were expressed using frequency and percentage and numerical variables as mean and standard deviation. One-way analysis of variance test was used for cross-comparison between groups. Results: A total of 35 patients developed PDPH. It was managed conservatively in 65.71%, with Sphenopalatine ganglion block (SPGB) in 28.57% and by epidural blood patch (EBP) in 5.72%. The mean age was 28.6 years and body mass index was 27.2. 25G spinal needle was used in 54.3% and 23G in 28.6%. At 30 minute, pain score was <4 in SPGB and EBP. At 2 hours, pain score was <4 in all patients. The difference in the drop in pain score was statistically significant with a P value of < .002 at all time points. On cross-comparison, conservative management with SPGB and blood patch was statistically significant. Conclusion: The incidence of PDPH was 0.8%. We can continue with the 23G and 25G Whitacre needles due to the incidence of PDPH being lower. The use of SPGB and EBP is effective in management of severe PDPH.

Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache after Cesarean Section: A Randomized Controlled Study

Abstract Background Post dural puncture headache (PDPH) is a known side effect following spinal anesthesia occurring in 2.5-40% of patients, it typically starts after 2 days but may be delayed up to 2 weeks and almost resolves spontaneously within a few days. Classic symptoms of PDPH consist of photophobia, nausea, vomiting, neck stiffness, tinnitus, diplopia and dizziness. Objective The aim of the study is to know if the neostigmine and atropine can improve PDPH treatment when added to conventional management after cesarean sections. Patients and Methods After obtaining approval from research ethics committee of Faculty of Medicine, Ain Shams University and after obtaining informed written consents from the patients. The study was conducted in the operating theaters of Ain Shams University Hospitals. The study period was 6 months after approval of the protocol, computer generated simple randomization. Patients with PDPH and a VAS < 5 were randomly allocated to receive either: Group 1: Slow intravenous injection with 20 µg/Kg neostigmine and 10 µg/Kg atropine in 20 ml 0.9% Saline given over 5 minutes every 8 hours up to 72 hours, Group 2: 20 ml of 0.9% saline intravenous every 8 hours. Results In this study, we compared the efficacy of neostigmine versus placebo (Both groups received the conventional management) in treating the PDPH, All of the 2 groups (neostigmine and Placebo) were effective in lowering VAS scores at 24, 48 and 72 h after headache's onset but neostigmine alleviated the pain more effectively and with rapid onset. The mean VAS score was significantly lower in neostigmine group compared with other group 6, 12, 24, 36, 48 and 72 h after start of medications (p < 0.001 for all of them) Placebo group 6, 12, 24, 36, 48, and 72 h (p < 0.001 for all of them). This may cause the drug to be one of the potential new drug therapies for such distressing condition, especially with its different mechanism of action that differs from other drugs. Conclusion Neostigmine/atropine was effective in treating PDPH after only 2 doses. Neostigmine can pass the choroid plexus but not the blood–brain barrier. The central effects of both drugs influence both cerebrospinal fluid secretion and cerebral vascular tone, which are the primary pathophysiological changes in PDPH. The results are consistent with previous studies and clinical reports of neostigmine activity.

Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache in Patients Undergoing Lower Abdominal Surgeries

Abstract Background Postdural puncture headache (PDPH) is a complication of spinal anesthesia or lumbar puncture and is an unpleasant experience for the patient as well as the anesthetist. It is thought to result from meningeal traction related to low cerebrospinal fluid (CSF) pressure or cerebral vasodilation as an indirect effect of decreased CSF pressure. Neostigmine is a reversible inhibitor of the enzyme cholinesterase, which results in an increased concentration of the neurotransmitter acetylcholine. It produces cholinergic-mediated analgesia and has been used as an adjunct analgesic postoperatively. Neostigmine can pass through the choroid plexus but not the blood–brain barrier, the central effect of both neostigmine and atropine influence both CSF secretion and cerebral vascular tone which are the primary pathophysiological changes in PDPH. Objective Assess the effectiveness of postdural anesthesia with addition of Neostigmine and Atropine versus conventional postdural anesthesia. Patients and Methods A 90 patients were included in our prospective randomized controlled double-blind study that was conducted at Ain Shams University Hospitals for 4 months on patients who fulfilled the inclusion criteria: patients with ASA Grade I & II, aged from (18 to 40) years old and scheduled for cesarean section. All patients aged >18 or <40, body weight >50, ASA III, IV, patients with uncontrolled chronic diseases such as hypertension, cardiac, renal, hepatic, cerebral diseases and peripheral vascular diseases, patients with history of PDPH, chronic headache, cluster headache, migraine, convulsions, cerebrovascular accident, signs of meningismus, preeclampsia, eclampsia coagulopathy, and previous neurological diseases and patients with history of bronchial asthma were excluded. Patients were divided into 2 groups: Group I (experimental group): neostigmine and atropine and Group II (placebo group): Saline placebo. Results The results of this study showed that incidence of postoperative headache was significantly lower among the intervention group, furthermore, VAS was significantly lower in the experimental arm versus placebo one. However, there was no significant difference regarding demographic, vital signs, and need for post-operative analgesia. The presented study showed that there is statistically non-significant difference between the studied groups regarding age, weight, and height and body mass index. There is statistically non-significant difference between the studied groups regarding duration of surgery. Conclusion After demonstrating many management options for post dural puncture headache (PDPH), in this study, we tried to prove the value of the use of neostigmine as a new management option that looks promising to alleviate the symptoms of such distressing condition. The current study results proved that the drug reduced the number of cases that experienced (PDPH) after spinal anesthesia for lower segment caesarean section, and how it prevent &control headache. A combination of neostigmine and atropine are effective in managing PDPH by reducing the associated VAS score and preventing persistence of headache.

Improving the Management of Postdural Puncture Headache—An International Clinical Guideline and Call for Better Evidence

Improving the Management of Postdural Puncture Headache—An International Clinical Guideline and Call for Better Evidence

Greater Occipital Nerve Block or Suboccipital Intramuscular Injections are effective for management of Postdural Puncture Headache: A placebo-controlled study

Greater Occipital Nerve Block or Suboccipital Intramuscular Injections are effective for management of Postdural Puncture Headache: A placebo-controlled study

Efficacy and efficiency of sphenopalatine ganglion block for management of post-dural puncture headache in obstetric patients: a randomized clinical trial

BackgroundThis clinical trial aimed to study the efficacy and efficiency of sphenopalatine ganglion block (SPGB) for the management of post-dural puncture headache (PDPH) in obstetric patients. A prospective randomized clinical trial was carried out on 40 patients with PDPH divided randomly into two equal groups. Paracetamol group (PG): The patients received 1 g of paracetamol three times per day intravenously for 1 day. If adequate pain relief was not achieved, rescue analgesia in the form of intravenous ketorolac was given. Block group (SPGBG): The patients received bilateral SPGB using 3 ml mixture of lignocaine with dexamethasone in each nostril. The pain score, heart rate, and mean arterial pressure were recorded. The onset of analgesia, duration of analgesia, adverse effects, total dose of ketorolac, patient satisfaction, and hospital stay for epidural blood patch (EBP) or hospital discharge after 24 h were also documented.ResultsThe pain perception (numeric rating scale [NRS]) in the block group was generally lower throughout the study showing only highly significant difference till the first 2 h after the block with more rapid onset and longer duration of analgesia. The total dose of rescue analgesic in mg was significantly lower in the block group and hospital stay for EBP was significantly less in the block group with higher patient satisfaction.ConclusionsPDPH can be treated effectively and rapidly with transnasal SPGB, which is a noninvasive, safe, and easy method with a low complication rate.Trial registrationClinicalTrials.gov, NCT04793490. Registered on March 11, 2021; https://clinicaltrials.gov/ct2/show/NCT04793490).

Comparative study between different approaches for the management of postdural puncture headache

Introduction The postdural puncture headache (PDPH) is one of the spinal and epidural anesthesia complications. It can be induced by using large gauge-cutting needles or performing numerous trials. Conservative treatment was the primary option for the management of PDPH, sphenopalatine ganglion block (SPGB) can be a suitable and safe option for the treatment of PDPH. Aim The aim was to verify the efficacy and safety of transnasal SPGB using either lidocaine 2% or bupivacaine 0.5% as a treatment line for PDPH versus the conventional conservative treatment. Patients and methods In total, 120 patients with PDPH following cesarean section under spinal anesthesia were assigned and divided into three groups. Group L (n=40) received transnasal SPGB (lidocaine 2%), group B (n=40) received transnasal SPGB (bupivacaine 0.5%), and group C (n=40) received conservative treatment for 24 h [intravenous (IV) paracetamol 1 g/8 h]. The headache severity was measured by the visual analog scale (VAS) at 0 min, 30 min, 6 h, 12 h, and 24 h post treatment. Results No significant difference in the VAS from the baseline between the groups L and B was observed. VAS values were significantly lower in both groups when compared with patients in group C (P<0.05). No significant differences from baseline mean blood pressure, heart rate, or other complications (such as bleeding), were observed between the three groups at any timepoint. Conclusion The headache severity in PDPH cases might be reduced more efficiently through SPGB using either lidocaine or bupivacaine, unlike other conservative treatments such as paracetamol.

A randomized control study to assess the efficacy of the sphenopalatine ganglion block in patients with post dural puncture headache.

Post dural puncture headache (PDPH) delays discharge from hospital. We studied the efficacy of sphenopalatine ganglion (SPG) block, a novel technique in management of PDPH using 0.25% Ropivacaine. Forty patients presenting with PDPH after urological procedures under spinal anaesthesia were randomized into two groups: Group C and Group S. Group C received conservative treatment with bed rest, adequate hydration and caffeine 200 mg 6th hourly. Group S patients received SPG block (packing bilateral nostril for 10 minutes with 0.25% Ropivacaine). Inj Paracetamol 1 g IV was given as primary analgesic. Intravenous Diclofenac 75 mg was administered as rescue analgesic. Patients were monitored for 72 hours. Total analgesic requirement, time to attain adequate pain relief, headache pain score, patient satisfactory score were compared between the two groups. We compared the PDPH severity score for headache using 5-point scale method and patient satisfaction score using Likert-type scale. Demographic data, onset of PDPH, needle size, intervention time were statistically insignificant. Total paracetamol consumption was significantly reduced in SPG group. Headache pain score was significantly low in Group S up to 54 hours. Patient satisfaction score was statistically better in Group S. Mean block onset time was 12 minutes. One patient in Group C required Epidural blood patch. SPG block is an effective alternative in managing patients with PDPH. The need for epidural blood patch is greatly reduced using SPG block. Procedural safety, immediate and sustained pain relief make it an evolving treatment modality for PDPH.

Factors associated with failed epidural blood patch after accidental dural puncture in obstetrics: a prospective, multicentre, international cohort study

BackgroundEpidural blood patch is commonly used for management of post-dural puncture headache after accidental dural puncture. The primary aim was to determine factors associated with failed epidural blood patch. MethodsIn this prospective, multicentre, international cohort study, parturients ≥18 yr receiving an epidural blood patch for treatment of post-dural puncture headache were included. Failed epidural blood patch was defined as headache intensity numeric rating scale (NRS) score ≥7 in the upright position at 4, 24, or 48 h, or the need for a second epidural blood patch, and complete success by NRS=0 at 0–48 h after epidural blood patch. All others were considered partial success. Multinominal logistic regression was used for statistical analyses with P<0.01 considered statistically significant. ResultsIn all, 643 women received an epidural blood patch. Complete data to classify failure were available in 591 (91.9%) women. Failed epidural blood patch occurred in 167 (28.3%) patients; 195 (33.0%) were completely successful and 229 (38.7%) partially successful. A total of 126 women (19.8%) received a second epidural blood patch. A statistically significant association with failure was observed in patients with a history of migraine, when the accidental dural puncture occurred between lumbar levels L1/L3 compared with L3/L5 and when epidural blood patch was performed <48 h compared with ≥48 h after accidental dural puncture. In patients having radiological investigations, three intracranial bleeds were diagnosed. ConclusionsFailed epidural blood patch occurred in 28.3% of women. Independent modifiable factors associated with failure were higher lumbar level of accidental dural puncture and short interval between accidental dural puncture and epidural blood patch. A history of migraine was associated with a higher risk of second epidural blood patch. Clinical trial registrationNCT02362828.

Sphenopalatine Ganglion Block versus Conservative Management for Post Dural Puncture Headache in Cesarean Section

Introduction: Post-dural puncture headache is one of the frequently encountered and inevitable post-operative complications of the subarachnoid block. The primary treatment is always considered conservative management in such instances. However, an epidural blood patch remains an invasive gold standard treatment. Sphenopalatine ganglion block is propounded as minimally invasive with prompt and better outcomes. Objective: To assess the efficacy of Sphenopalatine ganglion block (SPGB) when compared to conservative management based on the onset of analgesia and its duration. Methods: This is a prospective study performed on 40 obstetrics patients who underwent Lower segment cesarean section in Lumbini Medical College and Teaching Hospital (LMCTH) who complained of Post dural puncture headache within 7 days. All the parturients are categorized into Group A, those who are treated with sphenopalatine ganglion block, and Group B, where post-dural puncture headache was treated with conservative management. Independent t-tests and Fischer’s test were used for statistical analysis. Results: The patients in group A showed positive outcomes where all of them were relieved of post-dural puncture headache within 10 mins after Sphenopalatine ganglion block (p&lt;0.001) and the mean pain score, based on a numerical pain rating scale was less or equal to 4 for the first 8 hours. Conclusions: Sphenopalatine ganglion block (SPGB) could be used as an effective first-line treatment modality in the management of post-dural puncture headache compared to conservative management.

Comparison of Sphenopalatine Block and Intravenous Paracetamol for the Treatment of Post-Dural Puncture Headache

Objective: To compare the effect of topical sphenopalatine block and intra venous Paracetamol in the management of post-Dural puncture headache.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Combined Military Hospital Peshawar Pakistan, from Jan to Aug 2021.&#x0D; Methodology: This experimental study was conducted on 153 patients who underwent lumbar puncture for any procedure and then suffered from post-Dural puncture headaches. Patients were randomized into two groups. Group A received the topical sphenopalatine block, while group B received the intravenous Paracetamol three doses 12 hours apart. Headache was recorded on Numeric pain score (NPS) 24 hours after the surgical procedure. Comparison in pain relief was compared in both groups at 1 hour, 12 hours, 24 hours and 48 hours.&#x0D; Results: Out of 153 patients randomized into two groups, 76 (49.7%) were categorized into Group-A, and 77 (50.3%) were categorized into Group-B. 63 (41.2%) were male, while 90 (58.8%) were female. The mean age of patients included in our study was 34.34 ± 4.33 years. Gynaecological/obstetric procedures 70 (45.7%) were the most common indication for lumbar puncture in our study. At 1, 12, 24 and 48 hours, pain relief was statistically significantly better in Group-A than in Group-B (p- value&lt;0.005).&#x0D; Conclusion: Sphenopalatine ganglionic block emerged as a better option for pain relief among patients suffering from post-Dural puncture headache than intravenous Paracetamol. In addition, immediate and short-term relief was better among patients who used sphenopalatine block.

Intravenous Adrenocorticotropic Hormone in the Treatment of Post-Dural Puncture Headache: A Case of Refractory to Multiple Epidural Patch

: Post-dural puncture headache (PDPH) is an iatrogenic complication. It can disturb daily activities and particularly breastfeeding after delivery. Epidural blood patch (EBP) is still a last resort and treatment of choice after administration of certain proposed drugs. The use of intravenous (IV) adrenocorticotropic hormone (ACTH) has been suggested for treatment even in refractory cases in a literature review. EBP is an invasive procedure and not desirable for most patients. The associated case report highlights the important role of ACTH in alleviating PDPH and its priority for administration prior to EBP. We hope this report prompts the anesthesiology community to provide a more evidence-based approach to the role of ACTH in the better management of PDPH.

Racial and Ethnic Disparities in the Management of Postdural Puncture Headache With Epidural Blood Patch for Obstetric Patients in New York State

Characterizing and addressing racial and ethnic disparities in peripartum pain assessment and treatment is a national priority. To evaluate the association of race and ethnicity with the provision and timing of an epidural blood patch (EBP) for management of postdural puncture headache in obstetric patients. This cross-sectional study used New York State hospital discharge records from January 1, 1998, to December 31, 2016, from mothers 15 to 49 years of age with a postdural puncture headache after neuraxial analgesia or anesthesia for childbirth. Statistical analysis was performed from February 2020 to February 2022. Patients' race and ethnicity (reported as provided by each participating hospital; the method of determining race and ethnicity [ie, self-reported or not] cannot be determined from the data) were categorized into non-Hispanic White (reference group), non-Hispanic Black, Hispanic, and other race and ethnicity (including Asian and Pacific Islander, American Indian, Alaskan Native, and other). The primary outcome was the rate of EBP use. The secondary outcome was the interval (days) between hospital admission and provision of EBP. Odds ratios (ORs) and 95% CIs of EBP use associated with race and ethnicity were estimated using mixed-effect logistic regression models, adjusting for patient and hospital characteristics. During the study period, 8921 patients (mean [SD] age, 30 [6] years; 1028 [11.5%] Black; 1301 [14.6%] Hispanic; 4960 [55.6%] White; and 1359 [15.2%] other race and ethnicity) with postdural puncture headache were identified among 1.9 million deliveries with a neuraxial procedure. Of these 8921 patients, 4196 (47.0%; 95% CI, 46.0%-48.1%) were managed with an EBP. A total of 2650 White patients (53.4%; 95% CI, 52.0%-54.8%) used an EBP; this rate was significantly higher than that among Hispanic patients (41.7% [543]; 95% CI, 39.9%-44.5%), Black patients (35.7% [367]; 95% CI, 32.8%-38.7%), or patients of other race and ethnicity (35.2% [478]; 95% CI, 32.6%-37.8%). Timing of EBP was at a median of 2 days (IQR, 2-3 days) after hospital admission for White patients compared with a median of 3 days (IQR, 2-4 days) for Hispanic patients, Black patients, and patients of other race and ethnicity (P < .001 for the comparison with White patients). After adjustment for patient and hospital characteristics, the EBP rate was not different between White and Hispanic patients (adjusted OR, 1.11; 95% CI, 0.94-1.30). It was significantly lower for Black patients (adjusted OR, 0.80; 95% CI, 0.67-0.94) and patients of other races and ethnicities (adjusted OR, 0.85; 95% CI, 0.73-0.99). In this study, significant racial and ethnic disparities in the management of postdural puncture headache with EBP were observed, with both lower rates and delayed timing, which may be associated with long-term adverse effects.

Topical Intranasal Lidocaine is not a Sphenopalatine Ganglion Block

(Reg Anesth Pain Med. 2021:46. PMID: 33323391) There is a complex network of nerves within the pterygopalatine fossa. The largest peripheral parasympathetic ganglion, located within the pterygopalatine fossa, is the sphenopalatine ganglion (SPG) which plays an important role in managing primary and secondary headache disorders. Recent interest exists in applying local anesthetics (LA) as an SPG block to manage headaches, especially postdural puncture headache management. This discourse reviews why intranasal LA application is not an acceptable and effective route for SPG block.

Transnasal Sphenopalatine Ganglion Block for Management of Postdural Puncture Headache in Non-Obstetric Patients.

This study investigated the efficacy and safety of transnasal sphenopalatine ganglion block (SPGB) for treatment of postural puncture headache (PDPH) in non-obstetric patients. This retrospective study was conducted at the Ankara Research and Educational Hospital, in Turkey, and included 26 non-obstetric patients (age, ≥18 years) who were diagnosed with PDPH and unresponsive to conservative therapy or unable to continue it because of side effects. Transnasal SPGB was performed in each nostril. Pain severity was assessed with the Visual Analogue Scale (VAS) at 15 min, 30 min, 24 h, and 48 h after the procedure, while patients were seated. The patients were monitored for 48 h for adverse effects (AEs). Patient treatment satisfaction was assessed at 48 h after the procedure by using the Patient Global Impression of Change (PGIC) scale. Headache at 15 min post-procedure was relieved rapidly. At 24 h post-procedure, nearly half of patients (42.3%) had no pain, and all patients (100%) had a VAS score of <3. Nasal discomfort, throat numbness, and nausea were AEs reported after SPGB; however, these AEs were completely relieved at 24 h after the procedure. According to the PGIC scale scores at 48 h post-procedure, 73.1% of patients evaluated themselves as "much improved" and 26.9% evaluated themselves as "very much improved". When PDPH does not respond to conservative treatment, it may be treated effectively with transnasal SPGB, which is a noninvasive, safe, well-tolerated, and straightforward method with a low complication rate.

P.55 Service evaluation of accidental dural puncture follow-up and outcomes in the Royal Gwent Hospital

Introduction: Post-dural puncture headache (PDPH) is among the most common complications of neuraxial obstetric anaesthesia, with symptoms ranging from mild headache to severe impairment. Following reports of maternal death associated with PDPH, [1] Knight M, Kenyon S, Brocklehurst P, et al. (Eds.) MBRRACE-UK. Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–12. NPEU University of Oxford 2014. Google Scholar the Royal Gwent Hospital introduced a more stringent protocol for follow up of patients with accidental dural puncture (ADP), in conjunction with the introduction of 18G Tuohy needles as standard, aiming to improve outcomes following ADP. [2] Russell IF. A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour. Int J Obset Anesth 2012;21:7–16. Google Scholar This service evaluation aims to review our compliance with the new follow-up protocol and review rates and management of PDPH following ADP.

Sphenopalatine Ganglion Block for the Treatment of Postdural Puncture Headache: A Randomized, Blinded, Clinical Trial

(Br J Anaesth. 2020;124:739–747) The epidural blood patch (EBP) has ∼75% success rate in the management of postdural puncture headache (PDPH). EBP is an invasive, painful, and resource-demanding treatment associated with a number of complications. There is evidence to suggest a topical sphenopalatine ganglion block (SPG) could be as effective as EBP at managing PDPH. This randomized blinded study aimed to investigate the effects of SPG block on pain scores and rescue procedures compared with placebo on adult patients with PDPH, fulfilling the criteria for EBP.

Peripheral Nerve Blocks for Postdural Puncture Headache: A New Solution for an Old Problem?

Postdural puncture headache (PDPH) is one of the earliest recognized complications of regional anesthesia after inadvertent dural puncture. Epidural blood patch (EBP) is the "gold standard" for the treatment of PDPH. Several alternatives have been suggested as peripheral nerve blocks. The aim of this systematic review was to find out the potential efficacy and safety of peripheral nerve blocks for the treatment of PDPH. The main databases were systematically searched in September 2020 for studies examining regional anesthesia and PDPH. Nineteen studies were identified, including a total of 221 patients. Sphenopalatine ganglion block, greater occipital nerve block, and lesser occipital nerve block were performed. All participants reported a numeric rating scale (NRS) <4 after peripheral nerve blocks at 1, 24 and 48 h. Only patients with PDPH after diagnostic lumbar puncture reported NRS ≥4 after 48 h. No major adverse events were reported. Approximately, 17% of patients underwent a second or more peripheral nerve blocks. In 30 participants, EBP was required. To our knowledge, this is the first systematic review on the use of peripheral nerve blocks to treat PDPH. Peripheral nerve blocks can be considered as analgesic options in the management of PDPH.

A Comprehensive Update on the Treatment and Management of Postdural Puncture Headache.

The purpose of this manuscript is to provide a comprehensive review of postdural puncture headache (PDPH) with a focus on epidemiology, pathophysiology, treatment, and prophylaxis. PDPH is an adverse iatrogenic complication of neuraxial anesthesia that occurs following inadvertent puncture of the dura after epidural or spinal anesthesia. The overall incidence of PDPH after neuraxial procedures varies from 6 to 36%. The occurrence of PDPH can lead to increased patient morbidity, delayed discharge, and increased readmission. PDPH is a self-limiting postural headache that most often will resolve within 1week, without need for treatment. Various prophylactic measures have been studied; however, more studies have been recommended to be undertaken in order to establish a proven benefit. For mild PDPH, conservative treatments are currently focused around bed rest, as well as oral caffeine. For moderate-to-severe PDPH, epidural blood patch (EBP) remains the most effective treatment; however, this invasive treatment is not without inherent risks. Further less invasive treatments have been explored such as epidural saline, dextran 40mg solutions, hydration, caffeine, sphenopalatine ganglion blocks, greater occipital nerve blocks, and surgical closure of the gap; all have shown promise. Further studies are essential to prove efficacy as well as safety over the proven treatment of epidural blood patches. There is still limited evidence in literature about the understanding of PDPH and optimal treatment.