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5 Articles in Volume 3, Issue #4
Lidoderm Studied for New Applications
Osteoarthritis of the Temporomandibular Joint
Post-dural Puncture Headache Treatment
Preventing Post-dural Puncture Headache
Psychological Dimension of Pain Management

Post-dural Puncture Headache Treatment

A case report on the use of a combination sumatriptan and Fioricet protocol in successful first-line treatment of post-dural puncture headache.

Editor’s note: an abstract of this case report was presented at the annual meeting of the European Society of Anesthesiologists on April 8, 2001 at Gothenburg, Sweden.

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.

Methods

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.

Statistical Analyses

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.

Results

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.

Patient History and Demographic Data
# Age Sex Past Medical History Indication Procedure Date of Procedure Onset of headaches
1 18 F Non Contributory C-Section Failed Epidural, then Spinal 3/20/1998 3/21/1998
2 47 F Migraine, Hypertension Cervical Radiculopathy Cervical Epidural Steroid 12/5/1997 12/6/1997
3 40 F Pituitary lesion, History of Chronic Headache, Memory loss Hemorrhoidectomy Spinal 8/7/1997 8/8/1997
4 54 F Hypertension, CAD, IDDM,Lymphoma Low Back Pain Lumbar Epidural Steroid 8/24/1997 8/25/1997
5 33 F Non Contributory Hemorrhoidectomy Spinal 2/11/1998 2/11/1998
6 27 F Non Contributory I&D Perianal Abscess Spinal 2/5/1998 2/7/1998
7 27 F Headache for 2 months Work-up for Headache Lumbar Myelogram 12/16/1997 12/16/1997
8 26 F Non Contributory Vaginal Delivery Lumbar Epidural Wet tap 8/27/1997 8/29/1997
9 55 F Septicemia, Hemi paresis S/P CVA R/O Meningitis Lumbar Puncture 9/7/1997 9/9/1997
10 38 F Asthma, Hemangiosarcoma Low Back Pain Lumbar Epidural Steroid 2/20/1998 2/20/1998
11 25 F Headache, Fever R/O Meningitis Lumbar Puncture 1/12/1998 1/12/1998
12 44 F Depression, Chronic Headaches Work-up for Headache Lumbar Puncture 12/24/1997 12/24/1997
13 50 F Frontal lobe Dementia, Ca Uterus Work-up Lumbar Puncture 8/26/1997 8/26/1997
14 34 M Non Contributory Cervical Radiculopathy Cervical Epidural Steroid 12/9/1997 12/9/1997
15 43 F Non Contributory C-Section Failed Epidural, then Spinal 3/23/1998 3/25/1998
16 17 F Non Contributory C-Section Failed Epidural, then Spinal 3/23/1998 3/24/1998

Table 1.

Symptoms, treatment and NPS with statistical analyses of results are presented in Table 2. Symptoms included postural headaches in all patients, nausea/vomiting in eleven patients, dizziness in ten patients, and photophobia in eight patients. None had signs of diplopia, blurred vision or signs of cranial nerve palsy. Every patient was on oral mild narcotics without significant relief. One patient was on intravenous narcotics, one had intravenous caffeine and one already had EBP with recurrence of headache.

Initially 13 patients (81%) reported the highest pain score NPS=10, and mean pain score (NPS-Pre) was 9.56 ± 0.96 (range, 7 to 10) (Figure 1). One hour after the administration of sumatriptan-Fioricet, mean pain score (NPS-Post) was reduced to 1.94 ± 2.14 (range, 0 to 5). Twenty four hours later, mean pain score (NPS-Follow up) was increased to 3.31 ± 3.75 (range, 0 to 10). Three patients had lower, five had same, and eight had higher pain score. Three patients (19%) reported highest pain score NPS=10. NPS was significantly reduced by 7.62 ± 2.19 (p<0.0001) and 6.25 ± 3.45 (p<0.0001) for NPS-Post and NPS-Follow-up, respectively. On the basis of these scores, the use of sumatriptan-Fioricet did make a difference on NPS among patients with PDPH. Success of treatment was considered as at least 50% reduction of pain score from initial presentation. Overall, 13 patients (81%) had lower pain score next day after the sumatriptan-Fioricet protocol and so the treatment protocol was considered successful in them.

Figure 1. Change of mean NPS before and after sumatriptan-fioricet treatment

Three patients were considered as failure. All of them received EBP with two responders. One patient (patient #14) continued to suffer from headaches during final follow-up after EBP and adrenocorticotropic hormone (corticotropin; ACTH) injection without relief.

Two patients in the case series had relative contraindication to an epidural blood patch. One (patient #4) was a Jehovah’s Witness and refused an epidural blood patch, another (patient #9) had septicemia and was on immunosuppressants S/P lung transplant. She carried risk for an epidural abscess and sumatriptan was a reasonable choice.

Discussion

To the authors’ knowledge, this is the first case series using a sumatriptan-Fioricet protocol. Sumatriptan is a selective serotonin agonist causing cerebral vasoconstriction and is highly effective in migraine attacks. During PDPH, the body attempts to compensate intracranial hypotension with cerebral vasodilation.1 These changes are similar to migraine attacks. Sumatriptan counteracts the vasodilation and causes relief from PDPH. Increase in blood flow velocities was recorded by transcranial doppler studies in internal carotid and middle cerebral arteries probably secondary to vasoconstriction of the large basal intracranial arteries after sumatriptan therapy.2 The efficacy and safety of sumatriptan in the treatment of migraine attacks has been established.3 However, coronary spasm, acute myocardial infarction, cardiac arrest and dysrrhythmias have been reported from its use.4-9 Sumatriptan should be avoided in patients with known coronary artery disease or with significant cardiovascular risk factors. Cardiovascular monitoring and resuscitation equipments are mandatory.

Use of sumatriptan for the treatment of PDPH has been rarely reported in the literature. Carp et al. reported successful use of sumatriptan in six patients with PDPH.10 Four patients had relief of PDPH with one dose and one patient needed a second dose for relief with overall success rate of 83%. Success with the second dose of sumatriptan after failed EBP was reported by another author.11 On the contrary, Lhuissier et al. reported three cases as failure, as single dose sumatriptan was ineffective.12

In this case series, adding Fioricet to sumatriptan in the treatment regimen of PDPH, the authors experienced excellent success without any complications. Fioricet is a combination of a barbiturate butalbital 50 mg., acetaminophen 325 mg., and caffeine 40 mg. Caffeine is a common therapeutic agent used for PDPH.13,14 The efficacy of intravenous caffeine is claimed to be as high as 71-75%.15,16 The authors rationalized this polypharmic protocol by wanting to apply the mild cerebral vasoconstriction effect of caffeine, the sedative effect of butalbital, and the mild analgesic effect of acetaminophen all combined with the initial cerebral vasoconstrictive effect of sumatriptan.

Originally described by Gormley,17 the epidural blood patch remains the best supported method of therapy of PDPH with claimed success rates of between 92% and 100%18 especially when performed immediately after the dural puncture. Undue delay in performing epidural blood patch may be a factor for serious side effects of dural puncture including subdural hematoma and cranial nerve palsies,19,20 therefore conservative therapy should be abandoned upon observation of persistent PDPH and cranial nerve palsies—in this situation, an epidural blood patch should be performed immediately.

The original claim of a high success rate of the epidural blood patch in the treatment of PDPH has been challenged.21-23 Occurrences of severe acute back pain with lumbovertebral syndrome has been reported after epidural blood patch.24,25 In some instances, chronic low back pain and radiculopathy have been attributed to epidural blood patch.26 Substantial concerns have been expressed about the safety of epidural blood patch patients with HIV and bacterimia.27,28 Presence of coagulopathy and septicemia are considered as contraindications for epidural blood patch by most authorities because of the possibilities of epidural hematoma and abscess formation.

Alternative treatments of PDPH have had various success rates. Noninvasive therapies include caffeine, theophylline, aminophylline, steroids and narcotics. Mild narcotics along with bed rest, oral fluids, and caffeinated beverages are probably the most common modes of therapy for PDPH. Efficacy of intravenous ACTH was established by Kshatri, et al.29 Invasive therapies include epidural infusion of normal saline, Dextran or even injection of gelatin into the epidural space.30-32

While an epidural blood patch needs active participation of at least one anesthesiologist. Sumatriptan may be administered by non-anesthesiologists in any facility with proper monitoring and resuscitation equipment. This allows much more flexibility in the management of PDPH. The authors believe that this new protocol may be adopted by emergency room physicians and primary care physicians (under certain guidelines) and may be used as the first line of therapy for greater efficiency as well as in situations where a contraindication to EBP exists.

Conclusions

A case study, by definition, is not conducted in a rigorous scientific manner (ie. a prospective, double blind, randomized study, having a control group and large sample size) and yet it can provide insight and practical observations useful to the practitioner. This case report of the treatment of PDPH with a sumatriptan-Fioricet combination experienced a success rate of 81%. The authors believe this technique can be used as a first line therapy for PDPH, while keeping epidural blood patch in reserve for resistant cases and patients with cranial nerve palsies, and cardiovascular disease.

Last updated on: December 22, 2011
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