E NARRATIVE REVIEW ARTICLE

Review of the Alternatives to Epidural Blood Patch

for Treatment of Postdural Puncture Headache in the
Parturient
Daniel Katz, MD, and Yaakov Beilin, MD
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Labor neuraxial anesthesia is commonly used in the parturient, and postdural puncture head-
ache is the most common complication of the technique. Although epidural blood patch is the
best treatment, there are some patients in whom this treatment is refused or contraindicated.
The goal of this article is to review the efficacy of the most studied alternate modalities to treat
postdural puncture headache. This will include a discussion of the various oral or intravenous
therapies and the non–blood-containing epidural injections. Last, the evidence behind interven-
tional pain modalities and acupuncture will be examined.  (Anesth Analg 2017;124:1219–28)

P
ostdural puncture headache (PDPH) has been a
known complication of neuraxial anesthesia since the
first spinal anesthetic was performed in 1898 by Bier.1
Bier attempted a spinal anesthetic on his research assistant,
Hildebrandt, but was not able to inject the local anesthetic,
so his research assistant then placed the spinal in Bier. The
spinal anesthetic worked, but Bier developed a severe posi-
tional headache that lasted 9 days during which time he
was confined to bed. Hildebrandt developed a headache
that lasted 4 days. PDPH is not only an issue for the anes-
thesiologist, because neurologists and internists may see
patients with PDPH after lumbar puncture or even spon-
taneous or traumatic cerebrospinal fluid leak. When PDPH
complicates neuraxial analgesia for labor and delivery, it
can be particularly distressing for both the obstetric anes-
thesiologist and the patient alike. Increased length of stay
and cost of care and decreased patient satisfaction can all
result from PDPH.2
Treatment options for PDPH vary greatly. Many insti-
tutions have no guidelines or protocols for prophylaxis or
treatment, which makes the management of PDPH quite
heterogeneous.3 Although few would argue that epidural
blood patch (EBP) is the definitive treatment, there is con-
siderable debate on which patients are candidates, how
soon after dural puncture EBP can be performed, and how
to manage the patient in whom initial EBP fails. In addition,
a subset of patients will either refuse the EBP or not be con-
sidered candidates because of a variety of factors including
but not limited to postpartum coagulopathy, fever, or pre-
eclampsia. Those with preeclampsia, even without a coagu-
lopathy, have altered cerebral perfusion,4–6 which could be
worsened by injecting blood into the neuraxis. The purpose
of this article is to review the efficacy of non-EBP treatment
modalities for the treatment of PDPH (Table).
From the Icahn School of Medicine at Mount Sinai, New York, New York.
Accepted for publication November 21, 2016.
Funding: None.
The authors declare no conflicts of interest.
Reprints will not be available from the authors.
Address correspondence to Daniel Katz, MD, 1 Gustave L Levy Pl, Box 1010,
KCC 8th Floor, New York, NY 10029. Address e-mail to Daniel.Katz@moun-
tsinai.org.
Copyright © 2017 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000001840
NONINVASIVE TREATMENTS
Conservative Management
Initial treatment regimens center on noninvasive modalities
to counteract the proposed mechanisms of PDPH; cerebro-
spinal fluid (CSF) loss and cerebral vasodilation. For exam-
ple, hydration therapy has been proposed to increase CSF
production.7 Although this modality has remained popular,
to date, there is no evidence to support its use.8
In addition to hydration therapy, other conservative
options include bed rest,9 supine/prone positioning,10–12
and abdominal binders.13,14 Bed rest comes with its own
potential complications including but not limited to throm-
boembolic disease such as deep venous thrombosis, which
may include cerebral vein thrombosis. Bed rest may be nec-
essary in the short term if symptoms are severe; however,
bed rest only alleviates the pain while in the supine posi-
tion but does not treat the headache—when the patient sits
up, the headache recurs.8 Prone positioning increases intra-
abdominal pressure raising epidural space pressure and
may provide symptomatic relief.12 Abdominal binders work
via the same mechanism and may alleviate the headache.14
To be effective, they must be tightly applied and can be very
uncomfortable for patients. There are currently no data to
support the claim that abdominal binders shorten the dura-
tion of PDPH; however, one small study of women receiv-
ing spinal anesthesia with a 22-gauge needle for cesarean
delivery was able to demonstrate a decrease in incidence
of the headache when the binder was applied immediately
after the procedure.13
Although there are no practice guidelines that recom-
mend when EBP is indicated, untreated PDPH has been
associated with rare complications such as cortical venous
thrombosis15 and subdural hematoma.16 As such, those
with severe headaches or those who have not responded to
conservative therapy in a timely manner may benefit from
invasive treatments such as EBP. Severe symptoms or focal
neurologic findings indicate imaging to exclude serious
intracranial pathology before attempting EBP or conserva-
tive therapy.
Pharmacologic Treatments
A host of medications have been trialed in the hope of find-
ing an effective noninvasive treatment for PDPH. Reviewing
every medication or formulation goes beyond the scope of

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 E Narrative Review Article

Table. Summary of Treatments

Summary of Treatments
Category Subcategory Modality Doses Reported Clinical Efficacy Additional Clinical Factors
Conservative therapies
Hydration N/A No benefit May lead to patient
discomfort because of
increased micturition
Bed rest N/A No benefit May cause complications
such as VTE
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Prone positioning N/A No benefit Uncomfortable for the

patient
Abdominal binders N/A May decrease Uncomfortable for the
headache when patient
applied soon after
dural puncture
Medical therapies
Methylxanthines Caffeine 300–500 mg PO or IV Decreased pain scores, Often well tolerated, readily
daily; 2–4 cups of decreased headache available
coffee daily persistence, and
decreased need
for supplementary
intervention
Theophylline 250 mg PO TID; 281.7 Decreased pain scores Narrow therapeutic window
mg PO TID; 200 mg
IV once
Aminophylline 250 mg IV over 30 Decreased pain scores
minutes for 2 days
HPA axis ACTH/cosyntropin 0.25–0.75 mg over Decreased pain scores Data highly conflicted;
4–8 h IV once; 1 mg and decreased need efficacy appears to be
IM once for EBP higher for prophylaxis
than for treatment
Hydrocortisone 200 mg/100 mg IV Decreased pain scores
followed by 100 mg
IV TID for 48 h
Other headache Sumatriptan 6 mg SQ once No benefit
medications
Methylergonovine 0.25 mg PO TID for Decreased pain scores Results from case series
24 h, if efficacious and decreased need only; no RCTs reported
repeated for 48 for EBP
more h
Gabapentin 200 mg PO once Decreased pain scores May be sedating
followed by 100–
300 mg PO TID; 300
mg PO TID
Pregabalin 150 mg PO daily for 3 Decreased pain scores May be sedating; least
days, then 300 mg amount of data regarding
PO daily for 2 days; breast-feeding
100 mg PO daily
Invasive therapies
Epidural injections Saline 20 mL injection once; Decreased pain scores Transient benefit if single
of nonblood continuous infusions shot with recurrence of
fluids headache at 24 h
Hydroxyethyl starch 20 mL injection daily Decreased pain scores Multiple injections required
for 2 d to sustain benefits
Fibrin glue 4 mL injection once Decreased pain scores Very small case series
only, no RCTs, should
be performed under
fluoroscopy, expensive,
only considered when
multiple EBP have failed
Epidural injections Dexamethasone 8 mg injection once No benefit
of medications
Morphine 3 mg injection once; Decreased pain scores Studies done with catheters
two 3 mg Injections and decreased need left in situ for second
24 h apart for EBP injection, postinjection
respiratory monitoring
may be required
(Continued )

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 Treatment of Postdural Puncture Headache
Table. Continued
Summary of Treatments
Category Subcategory Modality
Acupuncture General and auricular
Occipital nerve Greater and lesser
blocks
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Sphenopalatine Intranasal
nerve blocks
Abbreviations: ACTH, adrenocorticotropic hormone; EBP, epidural blood patch; HPA, hypophyseal-pituitary-adrenal; IM, intramuscular; IV, intravenous; PO, per os;
PRN, as needed; RCT, randomized controlled trial; TID, 3 times daily; VTE, venous thromboembolism.
this brief review. Therefore, a concise review of the more
commonly used medications will be provided.
Nonsteroidal Anti-inflammatory Drugs, Acetaminophen,
Barbiturates, and Combinations. First-line medications
that are often trialed in patients where a conservative
pathway is attempted are nonsteroidal anti-inflammatory
drugs, acetaminophen, opioids such as oxycodone, or
combination medications commonly prescribed for tension
and migraine headaches, where barbiturates (butalbital),
acetaminophen, and caffeine (discussed below) are added
in a single formulation. Data on the efficacy of these
medications are lacking, although they are often mentioned
in conservative treatment pathways and are often used in
control arms of other studies.17–19 A survey of practitioner
management regimens for PDPH performed by Baysinger
et al20 reported that medications such as nonsteroidal anti-
inflammatory drugs and opioids were employed by 87%
and 71% of respondents, respectively. The reported success
rates to these treatments, however, were low, with over
60% of respondents reporting that these medications were
successful less than 40% of the time, and 34% of respondents
reporting a success rate of less than 20%.
Methylxanthines. Methylxanthines, namely caffeine and
theophylline, are some of the most studied medications
for relief of PDPH. These medications treat PDPH
symptomatology by 2 mechanisms. First, these drugs
interfere with calcium uptake by the sarcoplasmic reticulum,
block phosphodiesterase, and antagonize adenosine,
which all result in cerebral vasoconstriction.21,22 Second,
methylxanthines increase CSF production by stimulating
sodium-potassium pumps.23
The data on caffeine are highly heterogeneous as both
intravenous (IV) and oral formulations at varying dosages
and intervals were utilized during the investigations. Most
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Doses Reported Clinical Efficacy Additional Clinical Factors
1, 2, and 3 sessions Decreased pain scores Case series only, labor
PRN intensive, requires
multiple visits
2 mL 0.5% Decreased pain scores Small studies, may require
bupivacaine; and decreased need multiple injections
4 mL 0.25% for EBP
levobupivacaine; 2
mL dexamethasone
(6.6 mg) with 2 mL
1% lidocaine; 4 mL
0.25% bupivacaine
with triamcinolone
20 mg
1 cotton-tip applicator Decreased pain scores Small case series,
soaked with 5% and decreased need applicators must be left
water-soluble for EBP in place for 10 minutes,
lidocaine per nare; 1 repeated blocks may be
cotton-tip applicator needed
soaked with 4%
lidocaine ointment
per nare
studies also had small sample sizes and different end points,
which further limits conclusions. Caffeine-dosing regimens
are usually in the 300- to 500-mg range administered orally
or intravenously twice per day.14 For comparison, a stan-
dard cup of coffee has between 50 and 100 mg caffeine.14
The oral bioavailability of caffeine approaches 100% with
little first-pass metabolism, so either route of administration
is acceptable.24
Camann et al25 enrolled 40 postpartum women and ran-
domly assigned them to either 300 mg oral caffeine versus
placebo and analyzed change in visual analogue scale (VAS)
at 4 and 24 hours along with the need for EBP. At 4 hours,
VAS scores in the caffeine group were lower (33 ± 6) than the
placebo group (49 ± 7); however, this difference was ablated
by 24 hours. The need for EBP trended in favor of caffeine use
(7/20 in caffeine group versus 11/20 in placebo group; relative
risk [RR], 0.64; confidence interval [CI], 0.31–1.3) but did not
meet statistical significance. Sechzer26 randomly assigned 41
patients to receive either IV caffeine or placebo and recorded
persistence of headache at 1 and 2 hours after intervention.
He found an RR of 0.29 (0.13–0.64) for persistent headache
for those in the caffeine group supporting its use. Caffeine is
not recommended in women with hypertension or seizure
disorder27 because therapeutic levels of caffeine have been
associated with central nervous system (CNS) toxicity and
atrial fibrillation.14,27 Also, 1 investigator reported seizures
after caffeine administration in a postpartum patient after a
500-mg IV infusion.28 Caffeine is excreted into breast milk
with milk to plasma ratios of 0.5 to 0.76.29,30 Amounts of caf-
feine excreted into breast milk are not likely to be clinically
relevant, although reports of infant sleep disturbance with
very heavy maternal caffeine use (10–20 cups per day) have
been reported.31
Theophylline has been used to treat PDPH, with both oral
(281.7 mg 3× per day)17 and intravenous regimens (200 mg
infused over 30 minutes once).32 Although the mechanism
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 E Narrative Review Article
of action is similar to caffeine, theophylline tends to be used
less than caffeine.7 This is likely because of both the narrow
therapeutic index with theophylline and the patient expe-
rience with caffeine. Mahoori et al18 conducted a study in
60 patients (31.6% female) who were randomly assigned
to receive either 250 mg theophylline or 500 mg acetamin-
ophen orally every 8 hours and evaluated VAS scores for
pain at 2, 6, and 12 hours after the initial dose. They found
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mean differences in VAS scores of −0.97 (CI, −1.69 to −0.25),
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−0.9 (CI, −1.72 to −0.08), and −1.57 (CI, −2.67 to −0.47) at 2, 6,
and 12 hours, respectively. Other studies have found simi-
lar results, although they were smaller studies.17,23,32,33 Less
than 1% of the maternal dose of theophylline is excreted
into breast milk.34 It has been associated with irritability
in young infants where mothers took a rapidly absorbing
formulation of a similar drug aminophylline.35 It is consid-
ered to be compatible with breast-feeding by the American
Academy of Pediatrics.36
Although the evidence for methylxanthines is limited,
it remains a popular treatment choice given its reported
efficacy, favorable side effect profile, and ease of use. The
authors of this article commonly suggest to their patients to
drink caffeinated coffee, which is generally well received by
the patient while deciding if they want an EBP or in those
who are not candidates. Our approach is in agreement with
a Cochrane review on the topic.37
Hypophyseal-Pituitary-Adrenal Axis. Medications, adreno-
corticotropic hormone (ACTH) and hydrocortisone, that
interact with the adrenocorticotropic hormonal axis have also
been proposed as a therapeutic option. The mechanism of
action by which these medications treat PDPH is unclear, but
several theories exist including expansion of blood volume
by releasing aldosterone,38 dural edema causing overlap of
dural hole,39 increasing CSF production through sodium
active transport,40 or increasing brain β-endorphins (see
Figure 1).41
Natural ACTH is a 39-amino-acid protein in which the
first 24 amino acids in the sequence provide its hormonal
activity.42 The remaining 15 amino acids are nonactive
and antigenic. Synthetic ACTH (cosyntropin) is an ana-
log of only the first 24 amino acids in the chain, giving it
hormonal efficacy with less antigenicity.42 Synthetic ACTH
infusions of 0.25 to 0.75 mg over 4 to 8 hours have mostly
been described in small case series,40,41,43,44 which limits
definitive conclusions. In 2004, Rucklidge et al45 randomly
assigned 18 female patients to intramuscular formulations
of synthetic ACTH or saline injections and tracked request
for EBP, as well as VAS pain scores. No significant differ-
ences were seen. Zeger et al46 randomly assigned 33 patients
with PDPH (60% female) to either cosyntropin or caffeine
and examined VAS scores and persistence of headache.
Both groups showed a decrease in VAS score, 80% in the
cosyntropin group versus 56% in the caffeine group 2 hours
after treatment, although there was no difference in the
need for supplemental analgesics between groups. Hakim38
administered 1 mg cosyntropin 30 minutes postdelivery in
90 patients (45 intervention versus 45 control) who experi-
enced accidental dural puncture (ADP) and found that less
patients developed PDPH (33.3% vs 68.9%; P = .001). Of the
patients that did develop headaches, fewer required EBP
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(11.1% vs 28.9%; P = .035). The use of ACTH seems promis-
ing; however, a Cochrane review on the topic37 does not rec-
ommend its use and the authors of this article agree because
the evidence is conflicting. No reports examining the use of
synthetic ACTH have been published, and its use in breast-
feeding “probably is compatible.”47
Both Noyan Ashraf et al19 and Alam et al48 examined
the effectiveness of a course of hydrocortisone, one of the
end hormones in the hypophyseal-pituitary-adrenal axis,
for PDPH. In each study, the participants received a bolus
(200 mg19 or 100 mg48 IV) followed by repeat 100-mg dosing
every 8 hours for 48 hours. VAS scores and the need for EBP
were examined. Statistically significant decreases in VAS
scores were found at 6, 24, and 48 hours in the hydrocorti-
sone group in both studies when compared with the control
arm. However, no difference in the need for EBP was found
in either study. Two other randomized controlled trials
(RCTs) did not demonstrate a benefit of corticosteroids, and
the authors of this article do not routinely use them for the
prevention or treatment of PDPH.49,50 A Cochrane review37
examining the potential use of hydrocortisone reports effi-
cacy in pain score reduction; however, the authors believe
better alternatives exist, such as caffeine, that are more
efficacious and have been more extensively studied. There
are currently no data reporting the transfer of exogenous
hydrocortisone into breast milk; however, it is unlikely that
it would pose a risk, because prednisone, a much more
potent corticosteroid is compatible with breast-feeding.36
Medications Effective for Headache and Neuropathic
Pain. Pharmacologic therapy with medications effective in
treating other headache and pain syndromes has also been
trialed. Sumatriptan, a serotonin type 1-d receptor agonist,
commonly used in treating migraines, showed promise in
early case series studies.51 However, to date, RCTs examining
its efficacy have yielded negative results,52,53 a finding that
is concordant with the conclusions from the Cochrane
review.37 Sumatriptan is excreted into human breast milk
in negligible quantities and is no longer expressed 8 hours
after a dose.54 It is classified as compatible with breast-
feeding.36 Methylergonovine, a commonly used uterotonic
agent, has also been used to treat migraines because of its
alpha activity.55 Hakim et al56 performed the largest case
series examining methergine for the treatment of PDPH. In
this series, 25 obstetric patients who developed PDPH after
spinal anesthesia in whom conservative therapy for 24 hours
failed were given oral methergine 0.25 mg 3 times per day
for 24 hours. If symptoms were reduced or resolved, the
treatment was continued for 48 additional hours. VAS scores
were tracked every 8 hours on a 1 to 10 scale. Every patient
except for one had improvement of symptoms with 16%
experiencing total resolution, and pain scores were reduced
by half the original value in 80% of patients. By day 3, 24
patients had resolution of the headache. One patient required
EBP. Although these results are impressive, RCTs should be
performed before drawing definitive conclusions and before
prescribing methylergonovine to treat PDPH outside the
context of a clinical trial. This is in contrast with the Cochrane
review that reports efficacy based on the aforementioned
results.37 Methylergonovine is excreted into breast milk in
very small amounts that are not clinically relevant.57 There is
ANESTHESIA & ANALGESIA
 Treatment of Postdural Puncture Headache
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some debate on the effect of methylergonovine with regard to
its effect on prolactin. Structurally similar to bromocriptine,
which is known to inhibit prolactin, methylergonovine
has been implicated in decreasing prolactin levels in the
immediate postpartum period.58 A case-control study of 20
women demonstrated a drop in prolactin levels that was
significant when mothers were treated for 7 days; however,
milk let down, milk volume, and infant weight gain were the
same between those treated and controls.59 It is considered to
be compatible with breast-feeding.36
Gabapentin, a synthetic analogue of γ-aminobutyric
acid, has also been investigated as a possible therapy.60–63
It has analgesic properties and can inhibit the sympathetic
pathway of pain,64 which may contribute to the pain of
PDPH.62 Gabapentin selectively inhibits alpha-2-delta pre-
synaptic voltage-gated channels that decreases calcium
influx inhibiting excitatory neurotransmitters from primary
afferent nerves. At the level of the spinal cord, gabapentin
modulates presynaptic N-methyl-d-aspartate receptors.65
A case series by Wagner et al62 examined 17 patients in
whom EBP was contraindicated, refused by the patient, or
was ineffective in treating the headache. All patients were
given a 200-mg per os (PO) load dose of gabapentin followed
by 100- to 300-mg maintenance doses 3 times daily (TID)
titrated to side effects. The most common reason for decreas-
ing dose was sedation. They found that 9 patients (53%) had
a decrease in VAS score of at least 2 of 10 points, as well as
the resumption of normal activities within 24 to 48 hours of
therapy initiation. It was found to be ineffective in 5 patients
(29%). In 2006, Erol61 randomly assigned 20 patients to
either 300 mg gabapentin PO TID or placebo and examined
an 11-point VAS score over 4 days. Statistically significant
reductions in scores were noted in the gabapentin group on
each day with mean differences of −1.6 (CI, −1.92 to −1.28),
−2.6 (CI, −2.87 to −2.33), −2.9 (CI, −3.1 to −2.7), and −1.6 (CI,
−1.74 to −1.46), respectively. Erol60 randomly assigned 42
patients (40% female) to either 300 mg gabapentin PO TID or
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Figure 1. The hypothalamic-pituitary-adrenal
(HPA) axis.
ergotamine and caffeine TID for 4 days. These investigators
found significant reductions in pain scores on day 2 (mean
difference [MD] −1.86; CI, −2.57 to −0.15) and day 3 (MD
−2.38; CI, −2.94 to −1.82) but not on day 1 or 4 of treatment
with gabapentin. We recommend gabapentin as a potential
therapeutic option, in line with the Cochrane review on the
topic.37 It should be noted that gabapentin crosses into breast
milk at 12% of maternal levels,66 which has led some investi-
gators to exclude lactating women from enrollment.62
Pregabalin, a medication with structural and mecha-
nistic similarities to gabapentin, has also been trialed.65,67,68
Compared with gabapentin, pregabalin has a higher affin-
ity for alpha-2-delta receptors, and analgesic efficacy cor-
responds to its affinity.69 Pregabalin also has greater oral
bioavailability, has a faster time to peak concentration, and
has a much shorter titration period.69,70 Huseyinoglu et
al67 randomly assigned 40 patients with PDPH to a prega-
balin regimen (150 mg/d for 3 days followed by 300 mg/d
for 2 days) or placebo. VAS pain scores were significantly
lower in the treatment group on days 2 to 5, and the treat-
ment group required less diclofenac breakthrough as well.
Mahoori et al71 randomly assigned 90 PDPH patients to
pregabalin, gabapentin, or acetaminophen and found sig-
nificant reduction in pain scores in both the gabapentin and
the pregabalin group compared with acetaminophen at 24,
48, and 72 hours. These reductions were more pronounced
in the pregabalin group, which led these investigators to
conclude that pregabalin is a more effective treatment than
gabapentin. More research is needed about pregabalin, but
we expect it will ultimately prove efficacious based on its
similar mechanism of action to gabapentin. The Cochrane
review also concluded that, at this time, there are insuffi-
cient data to recommend its use.37 Lactation studies with
pregabalin are small; however, recent data suggest that
0.2% of a 300-mg dose will pass into breast milk, which is
0.31 mg/kg/d in the infant.72 The significance of this dose
is unknown.
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 E Narrative Review Article
INVASIVE TREATMENTS
Occasionally, patients need or opt for invasive treatments,
but refuse or cannot safely receive EBP. When the use of
blood is refused or contraindicated, but access to the epi-
dural space is not, neuraxial injections of fluids or drugs
may be considered. More commonly, patients refuse or are
not candidates for epidural injection, but request additional
therapy beyond oral or parenteral medications. In these
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nopalatine ganglion [SPG] nerve block) or alternative treat-
ments (eg, acupuncture) may be offered.
Epidural Injections of Fluid
Non–blood-containing epidural injections have been tri-
aled to treat or prevent PDPH. Epidural saline has been
attempted for both prophylaxis and treatment of PDPH.73–77
Most studies have found saline to be less effective than EBP
and of transient benefit because the saline resorbs from the
epidural space. Bart and Wheeler78 randomly assigned 43
patients to either epidural injection of saline or blood. The
investigators found that, although both groups had nearly
100% relief of symptoms postinjection, at 24-hour follow-
up, up to 40% of those with 25-gauge dural punctures and
100% of those with 17-gauge dural punctures had recur-
rence of the headache. In the EBP group, 100% of patients
with a 25-gauge dural puncture and 73% of patients with
17-gauge dural puncture experienced relief of symptoms at
24 hours.
Epidural hydroxyethyl starch has also been attempted.79,80
Documented case series show limited effectiveness and the
need for multiple epidural injections to sustain the effect.
There are currently no trials comparing hydroxyethyl
starch with other treatment modalities including EBP. In an
attempt to mimic the sealing effect of an EBP, fibrin glue
derived from pooled plasma proteins has also been tri-
aled81,82 with some efficacy; however, the data are only from
very small case series, the procedure is invasive, and long-
term sequelae are unclear.
Epidural Injections of Medications
Given the effectiveness of parental steroids in certain stud-
ies,49,50 epidural injections of dexamethasone have also
been attempted. Najafi et al83 randomly assigned over 200
patients to either spinal anesthesia alone or spinal anes-
thesia followed immediately by epidural injection of 8 mg
dexamethasone. No decrease in either the incidence or the
severity of PDPH was seen.
Injections of epidural morphine were studied by 2 inves-
tigators. Cesur et al84 randomly assigned 52 parturients who
experienced ADP during epidural catheter placement for
cesarean delivery to either repeat epidural placement fol-
lowed by epidural postoperative pain control or a control
group who received either spinal or general anesthesia for
the cesarean delivery followed by intramuscular meperidine
and tramadol for postoperative pain control. In the epidural
group, patients with a general (nonheadache) pain score
greater than VAS 3 were given 3 mg epidural morphine. The
investigators found reductions in the incidence of PDPH
(7.1% vs 58%; P = .000), as well as decreased need for EBP
(3.6% vs 37.5%; P = .002) in the morphine group. In another
1224   
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study performed in laboring patients by Al-Metwalli,85 the
effect of epidural morphine was examined. Patients who
experienced ADP had the repeat epidural catheter left in
situ. After resolution of the anesthetic, 3 mg morphine was
administered through the catheter, which was then left in
situ for 24 hours. At the end of 24 hours, another dose of
3 mg epidural morphine was administered. The control
group received 2 epidural saline boluses. Of the 25 patients
in the morphine arm, only 12% developed a PDPH, none of
whom required EBP compared with 12 patients who devel-
oped PDPH in the saline arm where 6 required EBP (P < .05).
Although the focus of this article is on treatment modali-
ties, in this study morphine was used in both a prophylactic
and a therapeutic manner, and there are no studies examin-
ing the effect of epidural morphine in a purely therapeu-
tic setting. The authors of this article believe that epidural
morphine is promising, safe, and should be considered as
a potential modality for both prophylaxis and treatment
of PDPH. A limiting factor for its routine use might be the
requirement for postadministration respiratory monitoring
for 24 hours, which may preclude its use in outpatients or
patients pending discharge. In addition, to follow the proto-
col described by Al-Metwalli,85 the epidural catheter would
have to be left in situ for 24 hours unless a new epidural
injection could feasibly be performed.
Acupuncture
Small case series have demonstrated effectiveness in using
acupuncture to treat PDPH.86–88 Acupuncture is known to
have a suppressive effect on the trigeminal nucleus caudalis
(TNC),89 which may play a role in PDPH. Acupuncture may
also suppress nociception at the dorsal horn at the medulla
spinal level90 and may have an overall inhibitory effect on
the pain process.91 It should be noted that, in addition to
traditional acupuncture sites such as BL 2, 10, 60, 62, GB
20, L I4, LR 3, and SI 3 (head, hand, and foot), those opt-
ing for auricular acupuncture sites were treated at MA-TF1,
MA-AH9, and MA-AT1 bilaterally (see Figure 2). Dietzel
et al92 described a series of 5 patients with PDPH who
received acupuncture in lieu of EBP. After the treatments,
all patients exhibited at least a 50% reduction in symptom-
atology, with no patients requiring EBP.
Sharma and Cheam87 and Volkan Acar et al88 each pre-
sented 2 patients who were treated with acupuncture, and
in all 4 patients, an EBP was not required. Further study is
required to better determine its utility.
Occipital Nerve Blocks
Greater and lesser occipital nerve blocks have been utilized
to treat cluster and migraine headaches, as well as occipital
neuralgia.93,94 The greater occipital nerve is formed by sen-
sory fibers that originate at C2-C3 vertebrae, which pene-
trate the semispinalis capitis and trapezius muscles on their
route to the cranium.95–97 The sensory distribution extends
over the posterior aspect of the head traveling anteriorly
to the vertex abutting the area supplied by the ophthalmic
division of the trigeminal nerve.97,98 Local anesthetic injec-
tion of the nerve by landmark (lateral to the nuchal midline
and medial to the occipital artery99) or ultrasound guid-
ance96,99 (see Figure 3) blocks sensation to the skin, muscles,
ANESTHESIA & ANALGESIA
 Treatment of Postdural Puncture Headache
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and vasculature along the nerve distribution.100 In addition
to the somatic innervation, the TNC lies in close proximity
to the upper cervical nerve roots, and there appears to be an
overlap of sensory input between these structures.101 Dural
stretching may activate the TNC causing some of the pain
from PDPH, and this pathway may be blocked by greater
occipital nerve block (GONB).98,101
Data on the use of GONB for the treatment of PDPH
are sparse. A 3-patient case series97 with favorable results
has given rise to larger series and a small RCT. Niraj et
al101 recruited 24 patients in 19 of whom conservative treat-
ment had failed; 18 of 19 received GONB. In 12 patients
(66%), complete relief of headache was observed, whereas
6 patients (33%) experienced partial relief and requested
EBP. Akyol et al99 retrospectively reviewed 21 patients
April 2017 • Volume 124 • Number 4
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Figure 2 . Traditional and auricular acu-
puncture sites.
with VAS scores greater than 4 who were offered GONB
as part of a PDPH protocol. In this study, the investigators
demonstrated that in mild cases (VAS 4–6) they were able
to achieve 100% recovery by the 24th hour after GONB.
Patients with severe PDPH with a VAS of 7 to 9 were more
likely to have recurrence of symptoms, although all patients
in this study reported significant relief of symptoms. Naja
et al102 randomly assigned 50 patients with PDPH to either
nerve stimulator-guided greater and lesser occipital nerve
blocks versus conservative therapy. The investigators found
complete relief in 68.4% of patients after 1 to 2 blocks,
with an additional 31.6% requiring 4 blocks for total relief.
Potential complications of GONB include bleeding, infec-
tion, and intravascular injection.99 These complications can
be minimized through the use of proper sterile technique
Figure 3. Identification of the greater
occipital nerve (GON) and the occipital
artery (OA) via ultrasound.
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Figure 4. Advancement of local anesthetic soaked cotton-tip applicator for sphenopalatine ganglion block.
and the use of ultrasound guidance. Other side effects may
depend on the injectate. Injections that contain steroids may
cause alopecia and skin atrophy at the site if repeated injec-
tions are used.103
SPG Nerve Blocks
The SPG is an extracranial structure located within the ptery-
gopalatine fossa that contains sympathetic, parasympathetic,
and somatic sensory nerve fibers.104 It can be accessed via the
transnasal or transcutaneous approach, although only the
transnasal approach, using long cotton-tip applicators, has
been described in treating PDPH104–107 (see Figure 4). This
method is believed to work by blocking parasympathetic
outflow to cerebral vasculature, which halts vasodilation.108
Although different local anesthetics and concentrations have
been utilized, the largest case series presented by Cohen et
al106,107 demonstrated success with both 4% lidocaine solution
and 5% lidocaine ointment. In each case, the applicators were
placed one per nostril and left in place for at least 10 minutes.
The success rate was high with 69% of patients not requir-
ing EBP after treatment.106 Further study is required to better
determine its utility.
CONCLUSIONS
PDPH continues to be a major source of morbidity and dis-
satisfaction for parturients. Although the standard definitive
treatment is EBP, many patients are either not candidates
or refuse the invasive procedure. Multiple pharmacologic
interventions have been trialed with mixed results, and any
conclusions drawn are limited by small patient populations
and study heterogeneity. All IV and oral analgesics have
some utility but are generally limited by their duration of
action. Non–blood-containing epidural injections (saline,
hetastarch, fibrin glue) are of limited value because they are
invasive, and if an epidural technique is being performed,
injecting blood, which is known to work, is a better choice.
Data on epidural morphine are favorable and because of
its long duration of action may obviate the need for EBP.
1226   
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Finally, alternatives such as acupuncture and regional anes-
thesia (GONB and SPG blockade) show promise, but clini-
cal use is still in its infancy. E
DISCLOSURES
Name: Daniel Katz, MD.
Contribution: This author was the original contributor and author.
Name: Yaakov Beilin, MD.
Contribution: This author was the original contributor and author.
This manuscript was handled by: Jill M. Mhyre, MD.
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