The cause (CSF leakage through a dural hole producing a low CSF pressure) (1), mechanism (traction on the pain sensitive structures in the brain and vasodilation of the cerebral vessels when the patient is upright) (2), and duration (until the hole spontaneously heals and CSF pressure is restored; typically lasts a few days and rarely more than one week) (1) helps to define the condition known as PDPH and to suggest an approach to treatment.
Therapeutic alternatives to epidural blood patching include:
1. Bedrest
The symptoms of PDPH are alleviated by assuming the horizontal position. Attempts at prophylactic treatment by placing the patient horizontal for a period of time (eg. 24 hours) after a dural puncture have no effect on the incidence or duration of a PDPH; it only delays the onset of the PDPH until the patient ambulates (1).
2. Hydration
Normal hydration of the patient should be maintained. Extra hydration to help the body make more CSF does not alleviate the headache. Dehydration may make symptoms worse.
3. Analgesics
Narcotic analgesics and, in some instances, non-steroidal anti-inflammatory agents are often administered for symptomatic treatment of the headache.
4. Caffeine
Caffeine has been suggested as a mode of therapy to help constrict the vasodilated cerebral vessels. It is best administered early in the day so that patients can sleep at night. The dose of caffeine sodium benzoate is 500 mg intravenously which can be repeated once two hours later if the first dose does not have the desired effect (2).
5. Epidural saline injection
Boluses or infusion of epidural normal saline can help to transiently increase the epidural pressure, slowing the speed at which CSF leaks through the dural hole (3). This may speed the natural healing process. The bolus dose is 30-60 mls given 6 hourly for 4 doses. The rate of infusion is 1000 mls administered over a 24 hour period. Although epidural saline can be a useful technique, higher success rates are often achieved with epidural blood patches (4).
References:
1. Jones R J: The role of recumbency in the prevention and treatment of postspinal headache. Anesthesia and Analgesia 53:788-796, 1974
2. Sechzer PH: Post-spinal anesthesia headache treated with caffeine. Part II: Intracranial vascular distension, a key factor. Current Therapeutic Research 26:440-448, 1979
3. Usubiaga JE: Effect of saline injections on epidural and subarachnoid space pressures and relation to postspinal anesthesia headache. Anesthesia and Analgesia 46: 293-296, 1967
4. Bart AJ: Comparison of epidural saline placement and epidural blood placement in the treatment of post-lumbar-puncture headache. Anesthesiology 48:221-223, 1978