What are the treatment options for PDPH?
Conservative treatment consists of bed rest, hydration, nonsteroidal antiinflammatory medications, and opioid analgesics. Bed rest immediately following dural puncture does not prevent PDPH but only delays its onset and relieves the symptoms. Hydration also is ineffective in preventing PDPH but is important to ensure that dehydration does not exacerbate the headache.
Caffeine is an effective treatment in for PDPH with an overall success rate of 70-80%. Caffeine can be administered either orally in single dose of 300 mg or intravenously in a slow bolus of 500 mg. Although recurrence of headache is common, a repeated doses administered in 4-6 hour intervals are usually sufficient to bring sustained relief. The mechanism of action is thought to be a reversal of reflex vasodilation mediated through the blockade of cerebral adenosine receptors.
Epidural blood patch is curative with a success rate of 90-99% and is indicated when PDPH persists for more than 24 hours. Many epidural blood patch failures are likely due to improper identification of the epidural space or misdiagnosis of the headache. Typically 15 to 20 ml of autologous blood is injected into the epidural space at the level of the dural puncture. As much volume should be injected as possible but injection should stop when the patient begins to complain of back or leg discomfort. Fifteen milliliters of blood spreads over about 9 spinal segments in a primarily cephalad direction. It is thought that immediate relief of PDPH occurs because the mass effect of the blood displaces CSF and raises intracranial pressure. This mass effect disappears in about 7 hours. Eventually the clot tamponades the tear in the dura and allows CSF production to restore the intracranial pressure.
The injection of epidural saline in a single bolus (20-30 cc) or as a continuous infusion (1000-1500 cc/24 hours) can be used as a prophylactic measure or as treatment for established PDPH. Although immediate relief occurs in up to 90% of patients, headache returns in over half of patients. A second injection or a continuous infusion may be necessary to produce sustained relief.