Post-dural puncture headache in the parturient

Abstract 

The occurrence of post-dural puncture headache (PDPH) after accidental dural puncture in the obstetric patient is a debilitating condition. Classical PDPH is postural in nature and may be associated with photophobia, neck stiffness, and nausea and vomiting. PDPH is a diagnosis of exclusion and must be distinguished from other causes of postpartum headache. Various preventative measures have included threading of an intrathecal catheter via a Tuohy needle, injection of intrathecal saline at the time of puncture and prophylactic epidural blood patch (EBP). Management options aim to seal the dural puncture site, control cerebral vasodilatation and restore CSF volume. Conservative treatment includes rest, hydration and the prescription of simple analgesia, but these measures do not hasten the resolution of the headache, nor do they reduce the requirements for epidural blood patching. Pharmacological treatment includes cerebral vasoconstrictors such as caffeine, sumatriptan, and adrenocorticotropic hormone, which is thought to increase CSF production. These drugs do not prevent the need for EBP but may give symptomatic relief. EBP is the gold standard for PDPH treatment, but there is debate about when it should be done and how much blood to inject. The practice at most units is to delay EBP for 24–48 hours and inject approximately 20 ml of blood, but to stop injecting if the patient experiences backache. Long-term complications of EBP are rare and there is no contraindication to subsequent epidural analgesia.

Keywords: accidental dural puncture, anaesthetic techniques, complications, epidural blood patch, post-dural puncture headache