Drugs for treating headache after a lumbar puncture

Lumbar puncture is an invasive procedure by which medical personnel try to get a sample of cerebrospinal fluid though a needle inserted into the lower lumbar area for diagnostic purposes (i.e. meningitis or subarachnoid haemorrhage). It is also used to inject medications such as anaesthetics and analgesics to perform a regional anaesthesia or chemotherapy. 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. Numerous medications are used in clinical practice to treat PDPH, so the aim of this review was to assess the effectiveness of these drugs.

We included seven randomised clinical trials (RCTs), with a total of 200 participants, that  assessed six medications (caffeine, sumatriptan, gabapentin, hydrocortisone, theophylline and adrenocorticotropic hormone). Caffeine proved to be effective in decreasing the proportion of participants with PDPH persistence and those requiring supplementary interventions. Gabapentin, theophylline and hydrocortisone also proved to be effective, decreasing pain severity scores better than placebo or conventional treatment alone, respectively. A meta-analysis (combining of data) was not possible because all the included RCTs assessed different drugs or different outcomes. Lack of information to allow correct appraisal of the risk of bias and the small sample sizes (number of patients) of the RCTs may limit the conclusions of this review

Authors' conclusions: 

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, theophylline and hydrocortisone have also shown a decrease in pain severity scores when compared with placebo or conventional care.

There is a lack of conclusive evidence for the other drugs assessed (sumatriptan and ACTH).

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 studies and also the limited generalisability, as most participants were post-partum women in their 30s.

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Background: 

Post-dural puncture headache (PDPH) is the most common complication of lumbar puncture, an invasive procedure frequently performed in the emergency room. Numerous pharmaceutical drugs have been proposed to treat PDPH but there are still some uncertainties about their clinical effectiveness.

Objectives: 

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

Search strategy: 

The search strategy included the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2011, Issue 2), MEDLINE (from 1950 to June 2011), EMBASE (from 1980 to June 2011) and CINAHL (from 1982 to June 2011). There was no language restriction.

Selection criteria: 

We considered randomised controlled trials (RCTs) assessing the effectiveness of any pharmacological drug used for treating 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 the included studies assessed different sorts of drugs or different outcomes. We performed an intention-to-treat (ITT) analysis.

Main results: 

We included seven RCTs (200 participants) in this review (between 88% and 90.5% were women; mostly parturients (84% to 87%) after a lumbar puncture for a regional anaesthesia). Pharmacological drugs assessed were oral and intravenous caffeine, subcutaneous sumatriptan, oral gabapentin, oral theophylline, intravenous hydrocortisone and intramuscular adrenocorticotropic hormone (ACTH).

One RCT reported data about PDPH persistence of any severity at follow up (primary outcome); caffeine reduced the number of participants with PDPH at one to two hours when compared to placebo. Treatment with caffeine also decreased the need for a conservative supplementary therapeutic option. Treatment with gabapentin versus placebo reported better visual analogue scale (VAS) scores after one, two, three and four days; treatment with hydrocortisone plus conventional treatment showed better VAS scores than conventional treatment alone at six, 24 and 48 hours and treatment with theophylline showed a lower mean "sum of pain" when compared with placebo. Sumatriptan and ACTH did not show any relevant effect for this outcome.

There were no clinically significant drug adverse events.

The rest of the outcomes were not reported by the RCTs or did not show any relevant effect.