Drug therapy for treating post-dural puncture headache

Abstract

Background This is an updated version of the original Cochrane review published in Issue 8, 2011, on 'Drug therapy for treating post-dural punctureheadache'.Post-dural puncture headache (PDPH) is the most common complication of lumbar puncture, an invasive procedure frequentlyperformed in the emergency room. Numerous pharmaceutical drugs have been proposed to treat PDPH but there are still someuncertainties about their clinical effectiveness.ObjectivesTo assess the effectiveness and safety of drugs for treating PDPH in adults and children.Search methodsThe searches included the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 6), MEDLINE and MEDLINE inProcess (from 1950 to 29 July 2014), EMBASE (from 1980 to 29 July 2014) and CINAHL (from 1982 to July 2014). There were nolanguage restrictions.Selection criteriaWe considered randomised controlled trials (RCTs) assessing the effectiveness of any pharmacological drug used for treating PDPH.Outcome measures considered for this review were: PDPH persistence of any severity at follow-up (primary outcome), daily activitylimited by headache, conservative supplementary therapeutic option offered, epidural blood patch performed, change in pain severityscores, improvements in pain severity scores, number of days participants stay in hospital, any possible adverse events and missing data.Data collection and analysisReview authors independently selected studies, assessed risk of bias and extracted data. We estimated risk ratios (RR) for dichotomousdata and mean differences (MD) for continuous outcomes. We calculated a 95% confidence interval (CI) for each RR and MD. Wedid not undertake meta-analysis because the included studies assessed different sorts of drugs or different outcomes. We performed anintention-to-treat (ITT) analysis.Main resultsWe included 13 small RCTs (479 participants) in this review (at least 274 participants were women, with 118 parturients after alumbar puncture for regional anaesthesia). In the original version of this Cochrane review, only seven small RCTs (200 participants)were included. Pharmacological drugs assessed were oral and intravenous caffeine, subcutaneous sumatriptan, oral gabapentin, oralpregabalin, oral theophylline, intravenous hydrocortisone, intravenous cosyntropin and intramuscular adrenocorticotropic hormone(ACTH).Two RCTs reported data for PDPH persistence of any severity at follow-up (primary outcome). Caffeine reduced the number ofparticipants with PDPH at one to two hours when compared to placebo. Treatment with caffeine also decreased the need for aconservative supplementary therapeutic option.Treatment with gabapentin resulted in better visual analogue scale (VAS) scores after one, two, three and four days when comparedwith placebo and also when compared with ergotamine plus caffeine at two, three and four days. Treatment with hydrocortisone plusconventional treatment showed better VAS scores at six, 24 and 48 hours when compared with conventional treatment alone and alsowhen compared with placebo. Treatment with theophylline showed better VAS scores compared with acetaminophen at two, six and12 hours and also compared with conservative treatment at eight, 16 and 24 hours. Theophylline also showed a lower mean "sum ofpain" when compared with placebo. Sumatriptan and ACTH did not show any relevant effect for this outcome.Theophylline resulted in a higher proportion of participants reporting an improvement in pain scores when compared with conservativetreatment.There were no clinically significant drug adverse events. The rest of the outcomes were not reported by the included RCTs or did not show any relevant effect. Authors' conclusions None of the new included studies have provided additional information to change the conclusions of the last published version of the original Cochrane review. Caffeine has shown effectiveness for treating PDPH, decreasing the proportion of participants with PDPH persistence and those requiring supplementary interventions, when compared with placebo. Gabapentin, hydrocortisone and theophylline have been shown to decrease pain severity scores. Theophylline has also been shown to increase the proportion of participants that report an improvement in pain scores when compared with conventional treatment. There is a lack of conclusive evidence for the other drugs assessed (sumatriptan, adrenocorticotropic hormone, pregabalin and cosyntropin). These conclusions should be interpreted with caution, due to the lack of information to allow correct appraisal of risk of bias, the small sample sizes of the studies and also their limited generalisability, as nearly half of the participants were postpartum women in their 30s.