Postdural puncture headache and pregabalin

Post-dural puncture headache: the worst common complication in obstetric anesthesia

Ever since the first spinal anesthetic in the late 19th century, the problem of "spinal headache" or post-dural puncture headache (PDPH) has plagued clinicians, and more importantly, patients. It has long been realized that the headache and other symptoms that often occur after the entry of a needle into the subarachnoid space is somehow related to fluid loss, although the exact pathophysiology of the headache has really never been defined. With the introduction of pencil-point spinal needles for spinal anesthesia in pregnant women over the past 2 decades, the problem of PDPH in obstetrics has been more associated with accidental dural puncture during attempted epidural procedures. Accidental puncture probably occurs in about 1% of procedures, so with over 60% of pregnant women receiving epidural analgesia for labor, there are probably 20,000-50,000 obstetric patients with PDPH in the United States each year. In this article, we will discuss the current state of knowledge in this area, suggesting that the PDPH syndrome is more severe and often more long-lasting, with some potentially life-threatening complications (cerebral hemorrhage) than usually appreciated or admitted. While prevention and treatment options are still limited, with the only clearly effective treatment being the epidural blood patch, recognition of the PDPH syndrome in postpartum women by anesthesiologists and obstetricians, with aggressive follow-up and treatment, may help limit the associated morbidity and mortality.

Comparing the effect of pregabalin, gabapentin, and acetaminophen on post-dural puncture headache

Introduction:

Post-dural puncture headache (PDPH) is a common complication of lumbar puncture for any purpose. To avoid the need for invasive methods of treating PDPH such as blood patch, the search for novel pharmacological agents to manage PDPH continues. The aim of this study was to compare the effects of acetaminophen, gabapentin and pregabalin in controlling PDPH in patients who underwent surgery under spinal anesthesia.

Materials and Methods:

A total of 90 patients who underwent elective orthopedic surgery under spinal anesthesia and suffered from PDPH consequently were enrolled in this randomized trial. Patients were categorized randomly into three groups. Group A, B and C have received Acetaminophen, Gabapentin and Pregabalin (3 times a day for 3 days), respectively. The effect of medications on the severity of PDPH was evaluated and compared using visual analog scale (VAS).

Results:

The mean VAS score was significantly lower in pregabalin group compared with others 24, 48 and 72 h after the onset of headache (P = 0.001 for all of them) and lower in Gabapentin group compared with Acetaminophen group 24, 48 and 72 h after the onset of headache (P = 0.001 for all analyses). No adverse outcome was reported in groups.

Conclusion:

Pregabalin and gabapentin are both useful and safe in management of PDPH, but pregabalin is more effective in this regard.

[Post-dural puncture headache and blood-patch: theoretical and practical approach]

OBJECTIVE

To review the current research and formulate a rational approach to the physiopathology, cause and treatment of post-dural puncture headache (PDPH).

DATA SOURCES

Articles published to December 2011 were obtained through a search of Medline for the MeSh terms "epidural blood-patch" and "post-dural puncture headache".

STUDY SELECTION

Six hundred and eighty-two pertinent studies were included and 200 were analysed.

DATA SYNTHESIS

Resulting of a dural tap after spinal anaesthesia or diagnostic lumbar puncture or as a complication of epidural anaesthesia, PDPH occurs when an excessive leak of cerebrospinal fluid leads to intracranial hypotension associated to a resultant cerebral vasodilatation. Reduction in cerebrospinal fluid volume in upright position may cause traction of the intracranial structure and stretching of vessels. Typically postural, headache may be associated to nausea, photophobia, tinnitus or arm pain and changes in hearing acuity. In severe cases, there may be cranial nerve dysfunction and nerve palsies secondary to traction on those nerves. The Epidural Blood-Patch (EBP) is considered as the "gold standard" in the treatment of PDHP because it induces a prolonged elevation of subarachnoid and epidural pressures, whereas such elevation is transient with saline or dextran. EBP should be performed within 24-48hours of onset of headache; the optimum volume of epidural blood appears to be 15-20mL. Severe complications following EBP are exceptional. The use of echography may be safety puncture. The optimum timing of epidural blood-patch, the resort of repeating procedure if the symptomatology does not disappear, the alternative to the conventional medical treatment need to be determined by future clinical trial.