Abstract

Background

Post‐dural (post‐lumbar or post‐spinal) puncture headache (PDPH) is one of the most common complications of diagnostic, therapeutic or inadvertent lumbar punctures. Many drug options have been used to prevent headache in clinical practice and have also been tested in some clinical studies, but there are still some uncertainties about their clinical effectiveness.

Objectives

To assess the effectiveness and safety of drugs for preventing PDPH in adults and children.

Search methods

The search strategy included the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2012, Issue 5), MEDLINE (from 1950 to May 2012), EMBASE (from 1980 to May 2012) and CINAHL (from 1982 to June 2012). There was no language restriction.

Selection criteria

We considered randomised controlled trials (RCTs) that assessed the effectiveness of any drug used for preventing PDPH.

Data collection and analysis

Review authors independently selected studies, assessed risks of bias and extracted data. We estimated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous outcomes. We calculated a 95% confidence interval (CI) for each RR and MD. We did not undertake meta‐analysis because participants' characteristics or assessed doses of drugs were too different in the included studies. We performed an intention‐to‐treat (ITT) analysis.

Main results

We included 10 RCTs (1611 participants) in this review with a majority of women (72%), mostly parturients (women in labour) (913), after a lumbar puncture for regional anaesthesia. Drugs assessed were epidural and spinal morphine, spinal fentanyl, oral caffeine, rectal indomethacin, intravenous cosyntropin, intravenous aminophylline and intravenous dexamethasone.

All the included RCTs reported data on the primary outcome, i.e. the number of participants affected by PDPH of any severity after a lumbar puncture. Epidural morphine and intravenous cosyntropin reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to placebo. Also, intravenous aminophylline reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to no intervention, while intravenous dexamethasone increased it. Spinal morphine increased the number of participants affected by pruritus when compared to placebo, and epidural morphine increased the number of participants affected by nausea and vomiting when compared to placebo. Oral caffeine increased the number of participants affected by insomnia when compared to placebo.

The remainder of the interventions analysed did not show any relevant effect for any of the outcomes.

None of the included RCTs reported the number of days that patients stayed in hospital.

Authors' conclusions

Morphine and cosyntropin have shown effectiveness for reducing the number of participants affected by PDPH of any severity after a lumbar puncture, when compared to placebo, especially in patients with high risk of PDPH, such as obstetric patients who have had an inadvertent dural puncture. Aminophylline also reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to no intervention in patients undergoing elective caesarean section. Dexamethasone increased the risk of PDPH, after spinal anaesthesia for caesarean section, when compared to placebo. Morphine also increased the number of participants affected by adverse events (pruritus and nausea and vomiting)

There is a lack of conclusive evidence for the other drugs assessed (fentanyl, caffeine, indomethacin and dexamethasone).

These conclusions should be interpreted with caution, owing to the lack of information, to allow correct appraisal of risk of bias and the small sample sizes of studies.

Author(s)

Xavier Basurto Ona, Sonia Maria Uriona Tuma, Laura Martínez García, Ivan Solà, Xavier Bonfill Cosp

Abstract

Plain language summary

Drugs for preventing headache after a lumbar puncture

Lumbar puncture is an invasive procedure that medical personnel use to get a sample of cerebrospinal fluid for diagnostic purposes (e.g. to diagnose meningitis or subarachnoid haemorrhage) by inserting a needle into the lower spinal region. It can also be used to inject medications such as anaesthetics and analgesics (to perform regional anaesthesia), chemotherapy or radiological contrast agents.

Post‐dural puncture headache (PDPH) is the most common complication of a lumbar puncture. The symptoms are a constant headache that worsens in the upright position and improves when lying down and resolves spontaneously within five to seven days. Several interventions have been used before, during or immediately after lumbar puncture to prevent PDPH, but there are still uncertainties about their clinical effectiveness, especially regarding drug treatments. Therefore, the aim of this review was to determine the effectiveness of these medications to prevent PDPH in children and adults.

We included 10 randomised clinical trials (RCTs), with a total of 1611 participants, that assessed seven medications (epidural and spinal morphine, spinal fentanyl, oral caffeine, rectal indomethacin, intravenous cosyntropin, intravenous aminophylline and intravenous dexamethasone). Epidural morphine and intravenous cosyntropin proved to be effective at reducing the number of participants affected by PDPH of any severity after lumbar puncture compared to placebo. Aminophylline also reduced the number of participants affected by PDPH of any severity after a lumbar puncture compared to no intervention. Dexamethasone increased the risk of PDPH when compared to placebo after spinal anaesthesia for caesarean section.

Morphine also increased the number of participants affected by adverse events such as itching, nausea and vomiting. The other interventions (fentanyl, caffeine, indomethacin and dexamethasone) did not show conclusive evidence of effectiveness.

Combining data was possible only for subgroups of one study comparing different dosages of caffeine to placebo, because the other RCTs appraised diverse drugs, outcomes or populations.

A meta‐analysis (combining of data) was not possible because all the included RCTs assessed different drugs, different doses, different outcomes or different baseline participants' characteristics.

These conclusions should be interpreted carefully, given the lack of information to evaluate the risk of bias properly, and the small number of participants in the included studies.

Author(s)

Xavier Basurto Ona, Sonia Maria Uriona Tuma, Laura Martínez García, Ivan Solà, Xavier Bonfill Cosp

Reviewer's Conclusions

Authors' conclusions 

Implications for practice 

Available studies show that morphine, cosyntropin and aminophylline could be a first‐line drug therapy when trying to prevent post‐dural puncture headache (PDPH) after a lumbar puncture.

Epidural morphine and intravenous cosyntropin decreased the number of patients affected by PDPH of any severity after a lumbar puncture compared to placebo, especially in those patients with a high risk of PDPH, such as woman giving birth who have had an inadvertent dural puncture during administration of regional anaesthesia. Pruritus, nausea and vomiting due to morphine and urticaria due to cosyntropin are the adverse events reported but these are less frequent than the benefits, are not severe or life‐threatening and, if necessary, efficacious and safe drugs exist to treat them.

Aminophylline also provides the same benefit, reducing the number of participants affected by PDPH of any severity, but in this case when compared to no intervention and in patients undergoing spinal anaesthesia for elective caesarean section.

Dexamethasone increased the risk of PDPH, after spinal anaesthesia for caesarean section, when compared to placebo.

These conclusions should be interpreted with caution, owing to the lack of information to allow a complete appraisal of risk of bias and the small sample sizes of studies.

There is a lack of conclusive results for the other drugs assessed (fentanyl, caffeine, indomethacin and dexamethasone).

Implications for research 

Future research in this field should focus on the design of trials with larger samples (including the reporting of how sample size was determined) in order to provide more sound and accurate information on the effectiveness of drugs in this setting and situation.

The reporting of trials could also be improved by endorsing the CONSORT statement (Schulz 2010), which would allow a better appraisal of them for their potential inclusion into systematic reviews.

Get full text at The Cochrane Library