Post Dural Headache Treatments

Came across a wonderful list of drugs available for post-dural headaches:

If you can’t reach it, here is the list and more

Postdural Puncture Headaches: What Works, What Doesn’t, and What Is New.
Kristopher Schroeder,
ASRA newletter Aug. 2104, 13-14,23

  • often presents after day 7
  • headache worse upright; better lying down
  • ass’d nausea/vomiting, visual and auditory perturbations, vertigo or backache.
  • 72% better by self after 7 days; 87% resolve within six months
  • fluid loading, bedrest, abdominal binders
  • caffeine help, more an urban legend
  • epidural patch of 16-20 mls the gold standard RX and works 90% time
  • Sphenopalatine  ganglion block  5% water soluble lidocaine ointment in each nostril for 10 minutes. – 6/16 required second block; 10/16 were satisfied
    Sakr A, Rah K, Cohen S, Faloba K, Ramos D, Chiricolo A, Kudupudi A, Mohiuddin A, Chhokra R. Hunter CW.
    Can we offer sphenopalatine ganglion block for our obstetric patient following accidental dural puncture? (abstract)
    Reg Anesth Pain Med Fall 2013;A-162;jsessionid=5C650F0663342D9D6418B75868BB97EC?year=2012&index=1&absnum=5075
  • occipital nerve blockade  – I wrote about this before
    Post Dural Puncture Headache Relieved by Occipital Nerve Blocks
  • acupuncture
    Dietzel, J., et al. “Acupuncture for treatment of therapy-resistant post-dural puncture headache: a retrospective case series.” British journal of anaesthesia 111.5 (2013): 847-849.
    Points BL 2, BL 10, BL 60, BL 62, GB 20, LI 4 LR3, and SI 3  For auricular acupuncture, the needles were inserted bilaterally at points MA-TF1, MA-AH9, and MA-AT1. held in place 25 minutes  50% better with first RX ; 6/6 better

Below are a list of agents that could be used – there is no advice on use but:
Sumatriptan 6 mg im, ACTH 60 units IM, and tramadol (Ultram in Canada) 50 4x/day (or a long acting tramadol) seem a good combo though sphenopalatine block would be easy to do initially.

11. Collier BB. Treatment for post dural puncture headache. Br J Anaesth. 1994;72:366-371.
12. Kshatri AM, Foster PA. Adrenocorticotropic hormone infusion as a novel treatment for postdural puncture headache. Reg Anesth 1997;22:432-434.
13. Gupta S, Agrawal A. Postdural puncture headache and ACTH. J Clin Anesth
14. Ghai A, Wadhera R. Adrenocorticotrophic hormone – is a single dose sufficient for post-dural puncture headache? Acta Anaesthesiol Scand 2007;51(2):266-266.
15. Carter BL, Pasupuleti R. Use of intravenous Cosyntropin in the treatment of postdural puncture headache. Anesthesiology 2000;92:272-274.
16. Erol DD. The effect of oral gabapentin on postdural puncture headache. Acute Pain 2006;8:169.
17. Erol DD. The analgesic and antiemetic efficacy of gabapentin or ergotamine/caffeine for the treatment of postdural puncture headache. Adv Med Sci 2011;56:25-29.
18. Ashraf N, Sadeghi A, Azarbakht Z, Salehi S, Hamediseresht E. Hydrocortisone in post-dural puncture headache. MEJ Anesth 2007;19:415-422
19. Hakim S, Khan RM, Maroof M, Usmani H, Huda W, Jafri F. Methylergonovine maleate (methergine) relieves postdural puncture headache in obstetric patients. Acta Obstet Gynecol Scand 2005;84:100-100.
20. Sheen MJ, Ho ST. Mirtazapine relieves postdural puncture headache. Anesth Analg 2008;107:346-346.
21. Zencirci B. Postdural puncture headache and pregabalin. J Pain Res 2010;3:11-14.
22. Carp H, Singh PJ, Vadhera R, Jayaram A. Effects of the serotonin-receptor agonist sumatriptan on postdural puncture headache: report of six cases. Anesth Analg 1994;79:180-182.
23. Connelly NR, Parker RK, Rahimi A, Gibson CS. Sumatriptan in patients with postdural puncture headache. Headache 2000;40:316-319.
24. Ergün U, Say B, Ozer G, Tune T, Sen M, Tüfekcioglu S, Akin U, Ilhan MN, Inan Intravenous theophylline decreases post-dural puncture headaches. J Clin Neurosci 2008;15:1102-1104.
25. Stephenson LL, Varness DC, Schroeder KM, Ford MP. Tramadol for postdural puncture headache treatment in a pediatric patient following failed blood patch. J Clin Anesth 2012;24:171-172.
26. Barodka V, Huffnagle S, Huffnagle S. Tramadol as a novel treatment for postdural puncture headache. Reg Anesth Pain Med 2007;32:A-60.


Comment – try drug measures and sphenopalatine and occipital blocks first, and then go for a patch after 7+days if no better would seem reasonable since so many get better by 1 week. Backache and paresthesias can occur. There are rare complications – subdural hematoma, arachnoiditis, infected EBP, facial nerve paralysis, and permanent spastic paraparesis but they are probably not much likely than with original epidural… maillotolympiquedemarseille maillotolympiquedemarseille

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