Drug therapy for treating post-dural puncture headache

The Prophylactic Effect of Acetaminophen and Caffeine on Post Dural Puncture Headache after Spinal Anesthesia for Cesarean Section: A Randomized Double-Blind Clinical Trial

Background

Post-dural puncture headache (PDPH) is the most common complication following spinal anesthesia among parturients undergoing cesarean section surgery. The purpose of this study was to evaluate the effectiveness of acetaminophen and caffeine in preventing PDPH.

Methods

This double-blind, randomized clinical trial was conducted on 96 obstetric women, who were candidates for elective cesarean section. Following the randomization of participants into two groups, participants in the intervention group received tablets of acetaminophen (500 mg)+caffeine (65 mg), and participants in the control group received placebo tablets orally 2 hours before spinal anesthesia induction and then every 6 hours after surgery up to 24 hours. All parturients were evaluated for frequency and intensity of PDPH every 6 hours until 24 hours after surgery and then 48 and 72 hours after surgery. Overall satisfaction during the first 72 hours of postpartum was evaluated. The data were analyzed using SPSS software. P<0.05 was considered statistically significant.

Results

Participants in the intervention group were 70% less likely to experience PDPH after spinal anesthesia (OR=0.31 P=0.01, 95% CI [0.12-0.77]). They also experienced significantly milder headaches 18 hours, 48 hours, and 72 hours later. Participants in the intervention group reported higher levels of satisfaction at the end of the study (P=0.01). No side effects related to the intervention were reported.

Conclusion

Prophylactic administration of acetaminophen+caffeine decreases 70% the risk of PDPH and significantly attenuates pain intensity in obstetric patients who underwent spinal anesthesia for cesarean section.

Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group

INTRODUCTION

Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH.

METHODS

Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach.

RESULTS

Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence.

CONCLUSIONS

These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.

Postdural Puncture Headaches in Pediatric Patients: A Review of Options When Repeated Epidural Blood Patches Do Not Work

We present the case of an adolescent with refractory postdural puncture headache (PDPH), whose symptoms resolved with a sphenopalatine ganglion (SPG) nerve block using a J-tip style catheter. Our patient was treated with multiple modalities, including conservative and medical management, multiple epidural blood patches, and different nerve blocks. We discussed different treatments for the PDPH, why each modality did not work, and why our SPG block with a J-tip catheter possibly provided a better sympathetic block in a patient with intractable PDPH for two weeks.

Post-caesarean Section Headache: A Case Report of Post-dural Puncture Headache and Cerebral Venous Thrombosis Following Epidural Anaesthesia

Post-dural puncture headache (PDPH) is a common complication of epidural and spinal anaesthesia in obstetric medicine. In rare cases, PDPH can be associated with complications such as cerebral venous thrombosis (CVT) as well. We discuss a recent case of a young female who developed PDPH and CVT concurrently after undergoing epidural anaesthesia for initially uncomplicated labour and delivered via an emergency caesarean section. She developed an orthostatic headache a few hours post administration of the epidural anaesthetic, which was initially treated as a suspected PDPH by giving simple analgesia and caffeine. Her symptoms did not improve and she underwent further neuroimaging, which revealed the development of a CVT. Despite the prompt administration of enoxaparin, the headache persisted and did not respond to increased doses of analgesia. After deliberation and inter-departmental discussion, an epidural blood patch was performed, leading to the prompt resolution of the headache. This report highlights a rare concurrence of PDPH and CVT, causing a diagnostic dilemma that resulted in treatment delays for the patient. Treating both conditions raises difficult practical questions, especially regarding the use of an epidural blood patch as opposed to anticoagulation. Given the risk of fatal complications such as venous cerebral infarction, seizures, and subdural hematoma, prompt treatment of both PDPH and CVT is strongly recommended. The multifactorial mechanism by which CVT develops with intracranial hypotension and PDPH also makes it essential for clinicians to keep an open mind when managing post-caesarean headaches, requiring inter-departmental cooperation to ensure optimal patient outcomes.

Ultrasonic optic nerve sheath diameter can be used as a diagnostic measure after accidental dural puncture during cesarean section: a case report

BACKGROUND

Parturients are prone to postdural puncture headache (PDPH) after epidural puncture. Cerebral venous sinus thrombosis (CVST) is a fatal complication of PDPH. The main symptom of both is headache, however, the mechanism is not similar. For persistent PDPH, early differential diagnosis from CVST is essential. Optic nerve sheath diameter (ONSD) measurements can be used to identify changes in intracranial pressure as an auxiliary tool to distinguish the cause of headache.

CASE PRESENTATION

The dura of a 32-year-old woman undergoing cesarean section was accidentally penetrated while administering epidural anesthesia, and the patient developed PDPH the subsequent day. The patient refused epidural blood patch (EBP) treatment and was discharged after conservative treatment. Fourteen days post-discharge, she was readmitted for a seizure. Magnetic resonance imaging (MRI) and Magnetic resonance angiography (MRA) indicated low cranial pressure syndrome and superior sagittal sinus thrombosis with acute infarction. The next morning, the EBP was performed with 15 ml autologous blood. Subsequently, the headache symptoms decreased during the day and worsened at night. ONSD measurement suggested dilation of the optic nerve sheath, and subsequently, the patient showed intracranial hypertension with papilledema. After dehydration and anticoagulant treatment, the patient's symptoms were relieved and she was discharged from the hospital 49 days later.

CONCLUSIONS

Headache is the main symptom of PDPH and cerebral venous thrombosis, which are difficult to distinguish. ONSD measurement may help to estimate the intracranial pressure, and early measurement may be helpful for women with PDPH to avoid serious complications, such as CVST.

Theophylline, a drug efficient to increase intracranial pressure. Case report and review of literature

Introduction

Limited information is available regarding the direct effect of drugs prescribed to elevate intracranial pressure (ICP) in contrast to the abundance of evidence in support of medication utilized to lower ICP. Theophylline is a methylxanthine derivate used in the treatment of respiratory diseases with only a few randomized control trials or case reports describing pain improvement in low CSF pressure states or spontaneous intracranial hypotension (SIH). We present the case of a recorded increase in intracranial pressure under theophylline.

Case report

A 23-year-old female with a complex history of hydrocephalus and syringomyelia was experiencing debilitating symptoms due to refractory intracranial hypotension. Medical management with oral theophylline was attempted for a period of three months. Intracranial pressure measurements were obtained via the telemetric pressure sensor reservoir (Miethke®, M.scio®) incorporated in the patient's ventriculoperitoneal shunt system.

Results

A significant increase in intracranial pressure was recorded at therapeutic drug levels.

Conclusion

This is the first report of an increase in intracranial pressure under oral theophylline medication.

The Spectrum of Headache in Leptomeningeal Metastases: A Comprehensive Review with Clinical Management Guidelines

PURPOSE OF REVIEW

Headaches are a common, oftentimes debilitating symptom in patients with leptomeningeal metastases.

RECENT FINDINGS

The third edition of the International Classification of Headache Disorders provides a useful diagnostic framework for headaches secondary to leptomeningeal metastases based on the temporal relationship of headache with disease onset, change in headache severity in correlation with leptomeningeal disease burden, and accompanying neurologic signs such as cranial nerve palsies and encephalopathy. However, headaches in patients with leptomeningeal metastases can be further defined by a wide range of varying cancer- and treatment-related pathophysiologies, each requiring a tailored approach. A thorough review of the literature and expert opinion on five observed headache sub-classifications in patients with leptomeningeal metastases is provided, with attention to necessary diagnostic testing, recommended first-line treatments, and prevention strategies.

Incidence and Severity of Post-dural Puncture Headache in Non-obstetric Patients Undergoing Subarachnoid Block

Background and goal of the study Post-dural puncture headache (PDPH) is a complication of central neuraxial block, either subarachnoid block (SAB) or epidural block. This clinical entity has a wide incidence and is affected by factors such as age, gender, needle gauge, needle shape/type, number of puncture attempts, and previous history of headache. Due to the lack of data in the non-obstetric population, this study assesses the incidence and severity of PDPH after SAB. Materials and methods A prospective observational study was carried out on patients undergoing SAB during the last trimester of 2020. Data were recorded on the day of surgery, 48 hours, and seven days after surgery. Data collected included demographic and medical clinic information, SAB procedure details, and clinical outcomes related to the presence of PDPH. Results and discussion Overall, 143 patients were included (median age: 62 years; 53.1% were women (n=76)). Most patients were aged >60 years (55.9%; n=80) and ASA 2 classification (65.0%; n=93). The incidence of PDPH was 21.7% (n=31), and most cases were from inpatient surgery (58.3%, n=21). The incidence of PDPH was 2.5 times higher with the use of 25 gauge compared to the use of the 27 gauge needle and was more prevalent with the use of the Quincke needles. Conclusion Over 20% of patients undergoing SAB experienced PDPH. Previous history of headache, larger gauge, and the Quincke needle use were associated with a higher incidence of PDPH.

Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report

Importance

Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures, such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis, and management of this condition is, however, currently lacking.

Objective

To fill the practice guidelines void and provide comprehensive information and patient-centric recommendations for preventing, diagnosing, and managing PDPH.

Evidence Review

With input from committee members and stakeholders of 6 participating professional societies, 10 review questions that were deemed important for the prevention, diagnosis, and management of PDPH were developed. A literature search for each question was performed in MEDLINE on March 2, 2022. Additional relevant clinical trials, systematic reviews, and research studies published through March 2022 were also considered for practice guideline development and shared with collaborator groups. Each group submitted a structured narrative review along with recommendations that were rated according to the US Preventive Services Task Force grading of evidence. Collaborators were asked to vote anonymously on each recommendation using 2 rounds of a modified Delphi approach.

Findings

After 2 rounds of electronic voting by a 21-member multidisciplinary collaborator team, 47 recommendations were generated to provide guidance on the risk factors for and the prevention, diagnosis, and management of PDPH, along with ratings for the strength and certainty of evidence. A 90% to 100% consensus was obtained for almost all recommendations. Several recommendations were rated as having moderate to low certainty. Opportunities for future research were identified.

Conclusions and Relevance

Results of this consensus statement suggest that current approaches to the treatment and management of PDPH are not uniform due to the paucity of evidence. The practice guidelines, however, provide a framework for individual clinicians to assess PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management.

Recent advances in obstetric anaesthesia and critical care

Newer modalities in labour analgesia and anaesthesia for caesarean section including regional anaesthesia techniques and airway management are emerging constantly. Techniques such as point of care ultrasound, especially of the lungs and stomach and point of care tests of coagulation based on viscoelastometry are about to revolutionise perioperative obstetric care. This has improved the quality of care thereby ensuring good perioperative outcomes in the parturient with comorbidities. Critical care for obstetrics is an emerging field that requires a multidisciplinary approach with obstetricians, maternal-foetal medicine experts, intensivists, neonatologists, and anaesthesiologists working together with enhanced preparedness and uniform protocols. Newer techniques and concepts of understanding have thus been established in the traditional speciality of obstetric anaesthesia over the last decade. These have improved maternal safety and neonatal outcomes. This article touches upon some recent advances that have made a significant impact in the field of obstetric anaesthesia and critical care.

Post-dural puncture headache: a prospective study on incidence, risk factors, and clinical characterization of 285 consecutive procedures

Background

Lumbar puncture (LP) is a common and relatively safe neurological procedure. It can be complicated by post-dural puncture headache (PDPH) after both diagnostic and therapeutic procedures. The aim of this study is to identify the incidence, risk factors and clinical characterization of PDPH in the inpatient setting of the main tertiary neurology hospital in Kuwait.

Methods

We conducted a prospective observational cohort study that included patients who were admitted to neurology department at Ibn Sina hospital, Kuwait, from January 1, 2019 to December 31, 2020, on whom, LP was performed for diagnostic and/or therapeutic reasons. Multivariate logistic regression analysis was performed to evaluate the association between PDPH and different clinical parameters.

Results

A total of 285 patients were included; 225 females (78.9%), mean age of 32.9 ± 11.7 years. PDPH was reported by 84 patients (29.5%), with mean headache onset of 1.7 ± 0.8 days, and mean duration of 2.4 ± 2.1 days. The commonest headache type was dull aching in 49 patients (58.3%). Headache severity was mild to moderate in 64 patients (76.2%), with mean NRS of 4.1 ± 0.9. Most PDPH (99.3%) resolved with conservative medical management, with only 2 patients (0.7%) requiring epidural blood patch. In multivariate logistic regression model, there was a statistically significant correlation between development of PDPH and young age (p = 0.001), female gender (p = 0 .001), low BMI (p < 0 .001), pre-LP headache (p = 0.001), history of previous PDPH (p = 0.001), and number of LP attempts (p < 0.001). PDPH was statistically significantly higher in patients with optic neuritis (p = 0.009), and cerebral venous thrombosis (p = 0.007), and lower in patients with peripheral neuropathy (p = 0.011) and spinal muscular atrophy (p = 0.042).

Conclusions

Findings from clinical practice in the main tertiary neurology hospital in Kuwait were in line with literature findings. Younger age, female gender, lower BMI, pre-procedural headache, previous history of PDPH, and number of LP attempts were found to be independent risk factors for developing PDPH. To our knowledge, this study represents the first comprehensive description of PDPH in a population from the Arabian Gulf Region.

Postdural Puncture Headache-Risks and Current Treatment

PURPOSE OF REVIEW

This manuscript aims to review the risks and the current treatments for postdural puncture headache (PDPH).

RECENT FINDINGS

PDPH is a relatively frequent complication after neuraxial blocks. It is typically orthostatic in nature, presenting as a positional and dull aching or throbbing headache, with added dysregulation of auditory and/or visual signals. Certain characteristics, such as female sex and young age, may predispose patients to the development of PDPH, as may factors such as previous PDPH, bearing down during the second stage of labor, and the neuraxial technique itself. Long-term complications including chronic headache for years following dural puncture have brought into question of the historical classification of PDPH as a self-limiting headache. So far, the underlying mechanism governing PDPH remains under investigation, while a wide variety of prophylactic and therapeutic measures have been explored with various degree of success. In case of mild PDPH, conservative management involving bed rest and pharmacological management should be used as first-line treatment. Nerve blocks are highly efficient alternatives for PDPH patients who do not respond well to conservative treatment. In case of moderate-to-severe PDPH, epidural blood patch remains the therapy of choice. An interdisciplinary approach to care for patients with PDPH is recommended to achieve optimal outcomes.

Aminophylline for Prevention and/or Treatment of Post-Dural Puncture Headache: A Systematic Review and Meta-Analysis Study Protocol

Objectives

Post-dural Puncture Headache (PDPH) is prevalent among individuals undergoing lumbar punctures. The non-invasive effect of some drugs, such as aminophylline on PDPH has been investigated in several clinical studies. As there is no comprehensive systematic review and meta-analysis about the preventive and therapeutic effects of aminophylline on PDPH in the literature, the clinical effectiveness of this drug on the prevention and/or treatment of PDPH will be assessed in this study.

Methods

PubMed/MEDLINE, Embase, WoS (Clarivate Analytics), the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL Complete, Scopus, and Google Scholar as electronic databases will be precisely searched for clinical studies that assessed the effect of aminophylline on PDPH. Studies between 01-01-1980 and 30-06-2020 will be evaluated in this study, and there will not be any language restrictions. Contradictions between the reviewers within any phase of the study (screening, selecting, quality assessment, and data extraction) will be resolved by consensus; in case of unsolved disagreements, a third reviewer will eventually decide. The combination method will be applied according to the methodological resemblance in the selected articles using the Random Effect Model or the Fixed Effect Model. Also, for the included articles, forest plots will be drawn. For assessing statistical heterogeneity, the I² statistic and the Q-statistic test will be applied. In addition, funnel plots will be used for assessing non-significant study effects and potential reporting bias. Furthermore, Egger’s and Begg’s tests will be done, and publication bias will be indicated by significant findings (P < 0.05).

Conclusions

It is expected that the results of this study will be of benefit to researchers and clinicians for managing PDPH, and will be reported in conferences and publications.

[Post-dural puncture headache]

Post-dural puncture headache belongs to the group of secondary headache disorders and is a typical complication of intended or unintended dural puncture. The main symptom is orthostatic headache, which can be accompanied by neurological symptoms such as diplopia depending on the extent of the cerebrospinal fluid leak. The course of this headache is predominantly benign, showing spontaneous improvement over a couple of days, although severe cases are described in the literature. The following article provides an overview of the current knowledge about the headache's pathophysiology, diagnostic work-up and therapy.

Use of therapeutic caffeine in acute care postoperative and critical care settings: a scoping review

BACKGROUND

Caffeine is the most utilised psychoactive drug worldwide. However, caffeine withdrawal and the therapeutic use of caffeine in intensive care and in the perioperative period have not been well summarised. Our objective was to conduct a scoping review of caffeine withdrawal and use in the intensive care unit (ICU) and postoperative patients.

METHODS

PubMed, Embase, CINAHL Complete, Scopus and Web of Science were systematically searched for studies investigating the effects of caffeine withdrawal or administration in ICU patients and in the perioperative period. Areas of recent systematic review such as pain or post-dural puncture headache were not included in this review. Studies were limited to adults.

RESULTS

Of 2268 articles screened, 26 were included and grouped into two themes of caffeine use in in the perioperative period and in the ICU. Caffeine withdrawal in the postoperative period increases the incidence of headache, which can be effectively treated prophylactically with perioperative caffeine. There were no studies investigating caffeine withdrawal or effect on sleep wake cycles, daytime somnolence, or delirium in the intensive care setting. Administration of caffeine results in faster emergence from sedation and anaesthesia, particularly in individuals who are at high risk of post-extubation complications. There has only been one study investigating caffeine administration to facilitate post-anaesthetic emergence in ICU. Caffeine administration appears to be safe in moderate doses in the perioperative period and in the intensive care setting.

CONCLUSIONS

Although caffeine is widely used, there is a paucity of studies investigating withdrawal or therapeutic effects in patients admitted to ICU and further novel studies are a priority.

[Post-dural puncture headache]

Post-dural puncture headache belongs to the group of secondary headache disorders and is a typical complication of intended or unintended dural puncture. The main symptom is orthostatic headache, which can be accompanied by neurological symptoms such as diplopia depending on the extent of the cerebrospinal fluid leak. The course of this headache is predominantly benign, showing spontaneous improvement over a couple of days, although severe cases are described in the literature. The following article provides an overview of the current knowledge about the headache's pathophysiology, diagnostic work-up and therapy.

Dexamethasone and post-dural puncture headache in women who underwent cesarean delivery under spinal anesthesia: A systemic review and meta-analysis of randomized controlled trials

BACKGROUND

Post-dural puncture headache is a common complication after spinal anesthesia for women who undergo cesarean delivery. Intravenous (IV) dexamethasone has been used to reduce the incidence and severity of PDPH with controversial results. This Systemic review and meta-analysis aimed to assess the effects of IV dexamethasone on PDPH.

METHODS

This study is reported as per Preferred Reporting Items for Systematic and Meta-analysis. The primary outcome was the incidence and severity of PDPH. The secondary outcome variables were the postoperative total analgesic requirement and incidence of nausea and/or vomiting. Twelve randomized controlled trials with a total of 1548 women were included.

RESULTS

Intravenous (IV) dexamethasone had no effect on the incidence of PDPH (OR = 0.64; CI, 0.39 to 1.05; I2 = 71%, P = 0.08). Intravenous dexamethasone did not show a significant difference in the incidence of PDPH at 24 h at 48 h, and within one week postoperatively with p-values of less than 0.05. In a random-effect model, a pooled analysis showed that IV dexamethasone had no effect on the severity of PDPH in VAS (MD = 0.78; CI, -2.27 to 0.71; I2 = 98%, P = 0.30).

CONCLUSION

Intravenous dexamethasone failed to decrease the incidence and severity of PDPH in women who underwent cesarean delivery under spinal anesthesia.

Dural tear from diagnostic lumbar puncture followed by long-term morbidity: a case report

Background

Lumbar punctures are performed in different medical settings and are a key procedure in the diagnosis of several neurological conditions. Complications are rare and generally self-limiting. There are no reports of symptomatic accumulation of fluid in the epidural space after lumbar puncture in adults and there are no studies on long-term outcome after post dural puncture headache (PDPH).

Case

A lumbar puncture was performed in a 29 y.o. slender woman with unspecific symptoms to rule out neuro-infection. Next day MRI showed substantial accumulation of CSF in the epidural space from C2 to the sacrum dislocating the spinal chord in the spinal canal. The condition was ameliorated by epidural blood-patching. At 5 months she was still impaired by severe orthostatic headache.

Conclusions

The only plausible explanation for the massive CSF leak was a dural tear occurring during multiple attempts of lumbar puncture. Anterior dislocation of the spinal chord due to CSF leak is not a recognised complication to lumbar puncture. This complication was followed by long-term disability in our case. The diagnosis can be made by MRI. A difficult procedure with several attempts and use of traumatic technique may increase risk of this complication.

The Ambiguous Role of Caffeine in Migraine Headache: From Trigger to Treatment

Migraine is a chronic disorder, and caffeine has been linked with migraine for many years, on the one hand as a trigger, and on the other hand as a cure. As most of the population, including migraineurs, consume a considerable amount of caffeine daily, a question arises as to whether it influences their headaches. Indeed, drinking coffee before a migraine attack may not be a real headache trigger, but a consequence of premonitory symptoms, including yawning, diminished energy levels, and sleepiness that may herald a headache. Here, we aim to summarize the available evidence on the relationship between caffeine and migraines. Articles concerning this topic published up to June 2020 were retrieved by searching clinical databases, and all types of studies were included. We identified 21 studies investigating the prevalence of caffeine/caffeine withdrawal as a migraine trigger and 7 studies evaluating caffeine in acute migraine treatment. Among them, in 17 studies, caffeine/caffeine withdrawal was found to be a migraine trigger in a small percentage of participants (ranging from 2% to 30%), while all treatment studies found caffeine to be safe and effective in acute migraine treatment, mostly in combination with other analgesics. Overall, based on our review of the current literature, there is insufficient evidence to recommend caffeine cessation to all migraine patients, but it should be highlighted that caffeine overuse may lead to migraine chronification, and sudden caffeine withdrawal may trigger migraine attacks. Migraine sufferers should be aware of the amount of caffeine they consume and not exceed 200 mg daily. If they wish to continue drinking caffeinated beverages, they should keep their daily intake as consistent as possible to avoid withdrawal headache.

Symptomatic Intrathecal Hematoma following an Epidural Blood Patch for an Obstetric Patient with Postdural Puncture Headache: A Case Report and Synthesis of the Literature

Epidural blood patch (EBP), generally considered a low-risk procedure, can potentially lead to significant neurological complications. We report the case of a parturient who underwent an uneventful EBP for postdural puncture headache (PDPH) and subsequently presented with progressively worsening radicular symptoms. Magnetic resonance imaging (MRI) revealed an intrathecal hematoma, and conservative management with steroids led to complete recovery. Our case highlights the possibility of this rare complication following an uneventful procedure and the importance of prompt diagnosis and treatment to prevent serious adverse outcomes. Literature review, EBP alternatives, and strategies to minimize complications following blood patch will be discussed in this report.

Caffeine Uptake into the Vitreous after Peroral Coffee Consumption

INTRODUCTION

Caffeine and its metabolites have antioxidant activity, scavenging reactive oxygen species. The aim of our study was to measure caffeine concentrations in vitreous samples after peroral caffeine intake.

METHODS

This prospective study included patients scheduled for 23-G pars plana vitrectomy with membrane peeling due to epiretinal membranes. The study was performed in two parts: in the first part, patients were recruited into three different groups: group A consisted of habitual coffee drinkers who agreed to drink coffee containing 180 mg caffeine 1 h before surgery (n = 10), group B consisted of habitual coffee drinkers who were not offered coffee before surgery (n = 5), and group C consisted of non-habitual coffee drinkers, forming the control group (n = 5). In the second part (group D) patients (habitual coffee drinkers) agreed to give additional blood serum samples for measurement of caffeine concentration. Harvested samples of vitreous (groups A-D), epiretinal membranes (groups A-C), and blood serum samples (group D) were examined for concentrations of caffeine with gas chromatography-mass spectrometry.

RESULTS

Samples of 40 eyes of 40 patients were harvested. The concentrations of caffeine in the vitreous samples were 1,998 ± 967 ng/mL in group A and 1,108 ± 874 ng/mL in group B. In group C, caffeine concentrations were below 176 ng/mL in all vitreous samples. Both groups A and B had significantly higher concentrations of caffeine in the vitreous samples than group C (p < 0.002, p < 0.01, Mann-Whitney U test). Caffeine concentrations in epiretinal membranes were below the limits of detection. Correlation of caffeine concentrations between blood serum samples and vitreous samples in group D was high, with significantly higher caffeine concentrations in the blood serum.

CONCLUSION

Coffee consumption leads to significant caffeine levels in the vitreous compared to patients in the control group, and caffeine concentrations in the vitreous showed a high correlation to blood serum concentrations of caffeine after peroral coffee consumption.

Suboccipital Muscles Injection for Management of Post-Dural Puncture Headache After Cesarean Delivery: A Randomized-Controlled Trial

INTRODUCTION:

Post-dural puncture headache (PDPH) is a common complication following neuraxial anaesthesia that increases the duration of hospital stay.

AIM:

This study aims to evaluate the effectiveness of injection of the dexamethasone-lidocaine mixture in suboccipital muscles treatment of PDPH after cesarean section.

PATIENT AND METHODS:

A group of 90 females with PDPH following cesarean section under spinal anaesthesia were randomly allocated into two equal groups: study group (Group S) and control group (group C). All patients received bilateral intramuscular (in the suboccipital muscle) (Group S) (n = 45) patients received lidocaine 40 mg (2 mL of 2% solution) and dexamethasone 8mg in a total volume of 4 mL; whilst, patients in the control group (group C) (n = 45) received 4 mL normal saline. The primary outcome is the Visual Analogue Score for a headache at 24 hours after injection.

RESULTS:

Demographic data and the baseline, headache score, neck muscle spasm, and nausea were comparable in both groups. Group S showed lower headache score compared to group C at all the post-injection time points. All patients in group S showed resolution of nausea after the intervention; while none of the control group showed any improvement. All patients of group C needed rescue analgesia; while only 6 (13.3%) patients in group S asked for an analgesic. Time to the first analgesic request was longer in group S compared to group C (10.17 ± 7.96 hours versus 1.00 ± 0.00 hours, P < 0.001).

CONCLUSION:

Ultrasound-guided injection of the dexamethasone-lidocaine mixture in suboccipital muscles is effective management of PDPH after CS.

Neuraxial morphine after unintentional dural puncture is not associated with reduced postdural puncture headache in obstetric patients

STUDY OBJECTIVE

To examine the relationship between neuraxial morphine exposure after unintentional dural puncture and the risk for postdural puncture headache in obstetric patients.

DESIGN

Retrospective cohort study.

SETTING

Obstetrical unit at a tertiary care referral center.

PATIENTS

Parturients receiving labor epidural analgesia with recognized unintentional dural puncture.

INTERVENTIONS

Cases in which neuraxial morphine was given for any reason were compared to cases in which it was not for the outcome of postdural puncture headache.

MEASUREMENTS

Development of postdural puncture headache, headache severity, number of epidural blood patches, hospital length of stay.

MAIN RESULTS

Of the 80 cases that were included, 38 women received neuraxial morphine and 42 did not. There was no significant difference in the incidence of headache between the two morphine groups (Headache present: Morphine: 27/56 [48.2%], No morphine: 29/56 [51.8%]; Headache free: Morphine: 11/24 [45.8%], No morphine: 13/24 [54.2%], P = 0.84). There was no difference in the need for epidural blood patch (Morphine: 24/42 [57.1%], No morphine: 18/38 [47.4%], P = 0.50) and headache severity (mean headache pain score: Morphine: 7.9 ± 1.8 vs. No morphine: 7.3 ± 2.4, P = 0.58). Hospital length of stay was higher in the morphine group (4.4 ± 2.9 days vs. 3.0 ± 1.5 days respectively, P = 0.008). Using logistic regression, morphine did not affect headache risk after controlling for covariates (morphine vs. no morphine: adjusted OR 1.24 [0.75]; P = 0.72; pre-eclampsia vs. no pre-eclampsia: adjusted OR 0.56 [0.41], P = 0.42; cesarean vs. normal spontaneous vaginal delivery: adjusted OR 0.97 [0.67]; P = 0.96).

CONCLUSION

In cases of unintentional dural puncture, exposure to neuraxial morphine for any reason may not be protective against the risk of postdural puncture headache. Although an overall protective effect of neuraxial morphine was not observed in this study, its role in specific subsets of patients remains to be investigated.

Headache and Its Approach in Today's NeuroIntensive Care Unit

Headache is a very common symptom in the neurointensive care unit (neuroICU). While headache in the neuroICU can be caused by worsening of a pre-existing primary headache disorder, most are secondary to another condition. Additionally, headache can be the presenting symptom of a number of conditions requiring prompt recognition and treatment including subarachnoid hemorrhage, ischemic and hemorrhagic stroke, central nervous system infection, pituitary apoplexy, and cerebral vasoconstriction. The neuroICU also has a unique postoperative population in which postcraniectomy and postcraniotomy headache, postintravascular intervention headache, hyperperfusion syndrome, ventriculitis, medication overuse or withdrawal headache, and hypercapnia may be encountered. Management varies dramatically depending on the etiology of the headache. Overreliance on opiate analgesics may produce significant adverse effects and lengthen ICU stays. However, nonnarcotic medications are increasingly being recognized as helpful in reducing the pain among various postsurgical and headache patients. Taken together, a multimodal approach targeting the underlying pathology and choosing appropriate systemic and local analgesic medications may be the best way to manage headache in critically ill patients.

Headaches: a Review of the Role of Dietary Factors

Dietary triggers are commonly reported by patients with a variety of headaches, particularly those with migraines. The presence of any specific dietary trigger in migraine patients varies from 10 to 64 % depending on study population and methodology. Some foods trigger headache within an hour while others develop within 12 h post ingestion. Alcohol (especially red wine and beer), chocolate, caffeine, dairy products such as aged cheese, food preservatives with nitrates and nitrites, monosodium glutamate (MSG), and artificial sweeteners such as aspartame have all been studied as migraine triggers in the past. This review focuses the evidence linking these compounds to headache and examines the prevalence of these triggers from prior population-based studies. Recent literature surrounding headache related to fasting and weight loss as well as elimination diets based on serum food antibody testing will also be summarized to help physicians recommend low-risk, non-pharmacological adjunctive therapies for patients with debilitating headaches.

Consensus guidelines for lumbar puncture in patients with neurological diseases

Introduction

Cerebrospinal fluid collection by lumbar puncture (LP) is performed in the diagnostic workup of several neurological brain diseases. Reluctance to perform the procedure is among others due to a lack of standards and guidelines to minimize the risk of complications, such as post-LP headache or back pain.

Methods

We provide consensus guidelines for the LP procedure to minimize the risk of complications. The recommendations are based on (1) data from a large multicenter LP feasibility study (evidence level II-2), (2) systematic literature review on LP needle characteristics and post-LP complications (evidence level II-2), (3) discussion of best practice within the Joint Programme Neurodegenerative Disease Research Biomarkers for Alzheimer's disease and Parkinson's Disease and Biomarkers for Multiple Sclerosis consortia (evidence level III).

Results

Our consensus guidelines address contraindications, as well as patient-related and procedure-related risk factors that can influence the development of post-LP complications.

Discussion

When an LP is performed correctly, the procedure is well tolerated and accepted with a low complication rate.

A case of paradoxical presentation of a postural postdural puncture headache after combined spinal-epidural anesthesia

We report a case of paradoxical presentation of a postural postdural puncture headache secondary to dural puncture with a 25-gauge Whitacre needle for combined spinal-epidural anesthesia. This 27-year-old female patient presented to the emergency department with elevated blood pressure and a global headache 9 days after administration of epidural anesthesia for a spontaneous vaginal delivery after an uncomplicated pregnancy. The patient reported that the headache was more intense when lying down and immediately improved when she sat or stood up from a recumbent position. The patient was discharged from emergency department after an improvement following treatment with labetalol, ondansetron, ketorolac, and fluid resuscitation.

Postdural puncture headache

Postdural puncture headache (PDPH) is a common complication after inadvertent dural puncture. Risks factors include female sex, young age, pregnancy, vaginal delivery, low body mass index, and being a non-smoker. Needle size, design, and the technique used also affect the risk. Because PDPH can be incapacitating, prompt diagnosis and treatment are mandatory. A diagnostic hallmark of PDPH is a postural headache that worsens with sitting or standing, and improves with lying down. Conservative therapies such as bed rest, hydration, and caffeine are commonly used as prophylaxis and treatment for this condition; however, no substantial evidence supports routine bed rest and aggressive hydration. An epidural blood patch is the most effective treatment option for patients with unsuccessful conservative management. Various other prophylactic and treatment interventions have been suggested. However, due to a lack of conclusive evidence supporting their use, the potential benefits of such interventions should be weighed carefully against the risks. This article reviews the current literature on the diagnosis, risk factors, pathophysiology, prevention, and treatment of PDPH.

Posture and fluids for preventing post-dural puncture headache

BACKGROUND

Post-dural puncture headache (PDPH) is a common complication of lumbar punctures. Several theories have identified the leakage of cerebrospinal fluid (CSF) through the hole in the dura as a cause of this side effect. It is therefore necessary to take preventive measures to avoid this complication. Prolonged bed rest has been used to treat PDPH once it has started, but it is unknown whether prolonged bed rest can also be used to prevent it. Similarly, the value of administering fluids additional to those of normal dietary intake to restore the loss of CSF produced by the puncture is unknown. This review is an update of a previously published review in the Cochrane Database of Systematic Reviews (Issue 7, 2013) on "Posture and fluids for preventing post-dural puncture headache".

OBJECTIVES

To assess whether prolonged bed rest combined with different body and head positions, as well as administration of supplementary fluids after lumbar puncture, prevent the onset of PDPH in people undergoing lumbar puncture for diagnostic or therapeutic purposes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and LILACS, as well as trial registries up to February 2015.

SELECTION CRITERIA

We identified randomized controlled trials that compared the effects of bed rest versus immediate mobilization, head-down tilt versus horizontal position, prone versus supine positions during bed rest, and administration of supplementary fluids versus no/less supplementation, as prevention measures for PDPH in people who have undergone lumbar puncture.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for eligibility through the web-based software EROS (Early Review Organizing Software). Two different review authors independently assessed risk of bias using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We resolved any disagreements by consensus. We extracted data on cases of PDPH, severe PDPH, and any headache after lumbar puncture and performed intention-to-treat analyses and sensitivity analyses by risk of bias. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created a 'Summary of findings' table.

MAIN RESULTS

We included 24 trials with 2996 participants in this updated review. The number of participants in each trial varied from 39 to 382. Most of the included studies compared bed rest versus immediate mobilization, and only two assessed the effects of supplementary fluids versus no supplementation. We judged the overall risk of bias of the included studies as low to unclear. The overall quality of evidence was low to moderate, downgraded because of the risk of bias assessment in most cases. The primary outcome in our review was the presence of PDPH.There was low quality evidence for an absence of benefits associated with bed rest compared with immediate mobilization on the incidence of severe PDPH (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.68 to 1.41; participants = 1568; studies = 9) and moderate quality evidence on the incidence of any headache after lumbar puncture (RR 1.16; 95% CI 1.02 to 1.32; participants = 2477; studies = 18). Furthermore, bed rest probably increased PDPH (RR 1.24; 95% CI 1.04 to 1.48; participants = 1519; studies = 12) compared with immediate mobilization. An analysis restricted to the most methodologically rigorous trials (i.e. those with low risk of bias in allocation method, missing data and blinding of outcome assessment) gave similar results. There was low quality evidence for an absence of benefits associated with fluid supplementation on the incidence of severe PDPH (RR 0.67; 95% CI 0.26 to 1.73; participants = 100; studies = 1) and PDPH (RR 1; 95% CI 0.59 to 1.69; participants = 100; studies = 1), and moderate quality evidence on the incidence of any headache after lumbar puncture (RR 0.94; 95% CI 0.66 to 1.34; participants = 200; studies = 2). We did not expect other adverse events and did not assess them in this review.

AUTHORS' CONCLUSIONS

Since the previous version of this review, we found one new study for inclusion, but the conclusion remains unchanged. We considered the quality of the evidence for most of the outcomes assessed in this review to be low to moderate. As identified studies had shortcomings on aspects related to randomization and blinding of outcome assessment, we therefore downgraded the quality of the evidence. In general, there was no evidence suggesting that routine bed rest after dural puncture is beneficial for the prevention of PDPH onset. The role of fluid supplementation in the prevention of PDPH remains unclear.

Drug therapy for treating post-dural puncture headache

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 8, 2011, on 'Drug therapy for treating post-dural puncture headache'.Post-dural puncture headache (PDPH) is the most common complication of lumbar puncture, an invasive procedure frequently performed in the emergency room. Numerous pharmaceutical drugs have been proposed to treat PDPH but there are still some uncertainties about their clinical effectiveness.

OBJECTIVES

To assess the effectiveness and safety of drugs for treating PDPH in adults and children.

SEARCH METHODS

The searches included the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 6), MEDLINE and MEDLINE in Process (from 1950 to 29 July 2014), EMBASE (from 1980 to 29 July 2014) and CINAHL (from 1982 to July 2014). There were no language restrictions.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) assessing the effectiveness of any pharmacological drug used for treating PDPH. Outcome measures considered for this review were: PDPH persistence of any severity at follow-up (primary outcome), daily activity limited by headache, conservative supplementary therapeutic option offered, epidural blood patch performed, change in pain severity scores, improvements in pain severity scores, number of days participants stay in hospital, any possible adverse events and missing data.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, assessed risk of bias and extracted data. We estimated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous outcomes. We calculated a 95% confidence interval (CI) for each RR and MD. We did not undertake meta-analysis because the included studies assessed different sorts of drugs or different outcomes. We performed an intention-to-treat (ITT) analysis.

MAIN RESULTS

We included 13 small RCTs (479 participants) in this review (at least 274 participants were women, with 118 parturients after a lumbar puncture for regional anaesthesia). In the original version of this Cochrane review, only seven small RCTs (200 participants) were included. Pharmacological drugs assessed were oral and intravenous caffeine, subcutaneous sumatriptan, oral gabapentin, oral pregabalin, oral theophylline, intravenous hydrocortisone, intravenous cosyntropin and intramuscular adrenocorticotropic hormone (ACTH).Two RCTs reported data for PDPH persistence of any severity at follow-up (primary outcome). Caffeine reduced the number of participants with PDPH at one to two hours when compared to placebo. Treatment with caffeine also decreased the need for a conservative supplementary therapeutic option.Treatment with gabapentin resulted in better visual analogue scale (VAS) scores after one, two, three and four days when compared with placebo and also when compared with ergotamine plus caffeine at two, three and four days. Treatment with hydrocortisone plus conventional treatment showed better VAS scores at six, 24 and 48 hours when compared with conventional treatment alone and also when compared with placebo. Treatment with theophylline showed better VAS scores compared with acetaminophen at two, six and 12 hours and also compared with conservative treatment at eight, 16 and 24 hours. Theophylline also showed a lower mean "sum of pain" when compared with placebo. Sumatriptan and ACTH did not show any relevant effect for this outcome.Theophylline resulted in a higher proportion of participants reporting an improvement in pain scores when compared with conservative treatment.There were no clinically significant drug adverse events.The rest of the outcomes were not reported by the included RCTs or did not show any relevant effect.

AUTHORS' CONCLUSIONS

None of the new included studies have provided additional information to change the conclusions of the last published version of the original Cochrane review. Caffeine has shown effectiveness for treating PDPH, decreasing the proportion of participants with PDPH persistence and those requiring supplementary interventions, when compared with placebo. Gabapentin, hydrocortisone and theophylline have been shown to decrease pain severity scores. Theophylline has also been shown to increase the proportion of participants that report an improvement in pain scores when compared with conventional treatment.There is a lack of conclusive evidence for the other drugs assessed (sumatriptan, adrenocorticotropic hormone, pregabalin and cosyntropin).These conclusions should be interpreted with caution, due to the lack of information to allow correct appraisal of risk of bias, the small sample sizes of the studies and also their limited generalisability, as nearly half of the participants were postpartum women in their 30s.