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It is important that a full history is taken and neurological examination performed, since there are many causes of postpartum headache (Table 44.1). Neurological referral may be wise in difficult cases. PDPH is suggested by a history of dural puncture and typical symptoms, especially the postural element. However, it may follow apparently unremarkable epidural anaesthesia; the incidence is unknown, although it may involve a number of factors including: lack of recognition at the time of dural puncture; lack of reporting dural puncture for fear of retribution; a possible tear of the dura but not arachnoid at the time of epidural insertion, with rupture of the arachnoid subsequently; and migration of the epidural catheter intrathecally during labour. It has been suggested that an otherwise typical PDPH that only becomes severe hours after getting up is caused by a very small dural hole with slow leak of CSF, e.g. after spinal anaesthesia with a very fine needle. A useful confirmatory sign is the lessening of headache produced by gradually compressing the upright patient's upper abdomen. This is thought to displace spinal CSF into the cranium by causing venous engorgement in the extradural space.

44 Postdural puncture headache 115

Table 44.1. Causes of postpartum headache

Tension, stress, fatigue, depression

Intracranial hypotension, e.g. postdural puncture headache

Intracranial hypertension, e.g. tumour, haematoma, cortical vein thrombosis, benign intracranial hypertension Migraine

Infection, e.g. meningitis, sinusitis, encephalitis Pre-eclampsia

Electrolyte imbalance, hypoglycaemia

Magnetic resonance imaging and computerised tomography scanning have been used to diagnose intracranial hypotension and to demonstrate cerebrospinal fluid leaks (in the latter case involving further diagnostic dural puncture), but are not widely used.

Initial management includes simple analgesics such as paracetamol and nonsteroidal anti-inflammatory drugs. Constipation (which causes straining) should be prevented if possible by avoiding opioids such as codeine or by offering lactulose. Although dehydration can exacerbate the headache, there is no evidence that overhydration has a beneficial effect. Other medical management includes oral caffeine 150-300 mg 6-8 hourly, which has been shown to improve the symptoms although not cure them. Caffeine may cause nausea and vomiting in overdosage and has been implicated in convulsions occurring after dural puncture. Successful use of the anti-migraine serotonin-receptor agonist sumatriptan (6mg subcutaneously) has been described anecdotally, as has adrenocorticotrophic hormone (ACTH; 1-5mU/kg in 1000-2000ml saline given intravenously over one hour). However, despite anecdotal reports of ACTH's synthetic analogue Synacthen being successful, a randomised controlled trial found no benefit of Synacthen 1 mg intramuscularly.

Invasive procedures involve infusion or injection of various substances into the extradural space, firstly to shift CSF from the spine into the skull and secondly to tamponade leakage of CSF through the dural hole and even to seal the hole. Saline infusions have been used both diagnostically and therapeutically, and dextran has been used in an attempt to provide longer-lasting relief. However, epidural blood patch (EBP) is now generally accepted as the definitive treatment in persistent PDPH, with a success rate of 70-100%, although headache may recur. Many anaesthetists would now proceed to EBP early (e.g. within 24-48 hours of symptoms) if there is a good history rather than delay for several days as was common previously.

Full discussion with, and support of, the patient is of prime importance, since she may be more distressed by apparent indifference to the severity of her symptoms than by the complication itself. She should be regularly visited and the various options discussed, preferably by a senior anaesthetist. If she decides against an EBP, she should be reassured that she may come back at any time should her symptoms persist. She should also be told about the rare possibility of serious sequelae.

It is not known whether EBP prevents these, although this is generally assumed if symptoms resolve. Postpartum follow-up at 6-10 weeks is recommended in order to check that symptoms have resolved and to advise about future pregnancies.

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