Post-dural Puncture Headache Treatment
Post-dural puncture headache (PDPH) may occur following any procedure in which a needle pierces the dura membrane of the spine and subsequently causes spinal fluid to leak out through the puncture hole. The resulting leakage reduces the spinal fluid pressure to the extent that the membrane at the base of the skull, separating spinal and brain fluid reservoirs, stretches and triggers adjacent nerves and thereby causing headaches whose severity correlates to the degree of pressure imbalance. Various treatment modalities have been tried for post-dural puncture headache (PDPH) among which epidural blood patch (EBP) remains as the “gold standard.” However EBP has its own limitations and complications—the procedure is involved and requires collection of blood from the patient and injection of the blood into the epidural space (see discussion section for contraindications of EBP.)
The authors used a combination of two migraine medications: sumatriptan (Imitrex, Glaxo-Welcome Pharmaceuticals, USA) and Fioricet (Sandoz Pharmaceuticals Corporation, USA) for the treatment of PDPH. The following case report is presented with a retrospective analysis of the results of this new treatment protocol.
Patients experiencing PDPH and who were referred to Henry Ford Hospital pain management center (Detroit, Michigan) between August 1997 and March 1998 were offered two treatment options: EBP or this new sumatriptan-Fioricet protocol. Only the patients who agreed to the sumatriptan-Fioricet protocol were included in the case report. Routine history and physical examination was performed in every patient with special emphasis on the cardiovascular system to rule out coronary artery disease, hypertension or arrhythmias. After initial evaluation and assessment, risks and benefits of EBP and sumatriptan-Fioricet protocol were explained to the patient and informed consent was obtained.
An intravenous infusion of Lactated Ringers (a sterile solution containing sodium chloride, sodium lactate, potassium chloride, calcium chloride dihydrate and water used as an aid in the treatment of dehydration and electrolyte disturbances) at 100 ml per hour was started and baseline vital signs and initial numerical pain scale (NPS) between 0 and 10 was noted. The patient received 6 mg of sumatriptan by the subcutaneous route while electrocardiography, blood pressure and pulse oximetry were continuously monitored for one hour. NPS was noted after one hour of the initial therapy. Fioricet at a dosage of one tablet every four hours was prescribed on an as-needed basis by the oral route for three days. If the patient had no relief from the initial dose of sumatriptan, an option of a second dose of sumatriptan or epidural blood patch was offered to the patient. After twenty-four hours, all patients were followed up via telephone by the pain clinic nurse and numerical pain scale rating was noted. A final follow-up was done after an elapsed time of between one and six months after initial therapy.
A Paired t test was used to analyze the changes in NPS before and after the treatment. A P value of <0.05 was considered to be statistically significant. Parameters are reported as mean ± standard deviation. The SAS statistical software version 8.1 for Windows (SAS Institute, Inc., Cary, NC) was used for all data analyses. Success was defined as at least 50% reduction from initial NPS at 24 hours follow-up.
Sixteen patients agreed to sumatriptan-Fioricet protocol and were included in this case series. The demographics, medical history and indications are presented in Table 1. Four patients had diagnostic lumbar puncture with 20 gauge lumbar puncture needle and one had lumbar myelogram. Two patients received lumbar epidural steroid injections and two received cervical epidural steroid injections without apparent wet taps during the procedure, but reported headaches with postural component afterwards. Three surgical patients had single shot uncomplicated spinal anesthesia with 25 gauge Quincke needles. Of the four obstetric patients in the series, technical difficulties were noted in all. Ot these, three patients had spinal anesthesia with 25 gauge Quincke spinal needles for cesarean section after multiple failed epidural attempts with 18 gauge Tuohy epidural needles. Only one patient had documented wet tap with an 18 gauge Tuohy needle and had vaginal delivery under intravenous sedation. Seven patients had the onset of headaches on the same day, five the following day and four after two days.