Post-Dural Puncture Headache
Conditions
Brief summary
Post-dural puncture headache (PDPH) is a common and debilitating complication of spinal anesthesia in pregnant patients undergoing cesarean sections, with an incidence ranging from 0.5% to 2% (1). The International Headache Society (IHS) defines PDPH as a headache occurring within 4 days of a lumbar puncture, caused by cerebrospinal fluid (CSF) leakage through the dural puncture (2). Although the exact cause of PDPH is not fully understood, it is thought to occur due to cerebrospinal fluid loss through dural tears, which leads to tension on pain-sensitive intracranial structures and reflex, uncontrolled cerebral vasodilation leading to severe agonizing tension headache (3). Treatment options include proper hydration, maintaining a supine position, caffeine, paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs). Many adjuvants have been questioned for their therapeutic effectiveness in enhancing conservative medical treatments, with conflicting results (4). For example, sumatriptan, theophylline and dexmedetomidine have been extensively studied. Neostigmine has emerged as a promising pharmacological adjuvant for conservative management. Neostigmine increases the serum level of acetylcholine via inhibition of cholinesterase (5). This action mediates cerebral vasoconstriction via nicotinic receptors, thus antagonizing the unopposed vasodilatation occurred due to dural tear. Lidocaine, on the other hand, can mediate sphenopalatine ganglion block which is responsible for pain signals transmission from the face (6).
Interventions
DRUGlidocaine group ( nebulized lidocaine + saline) total volume 4 ml
nebulization of 60 mg lidocaine in 4ml saline 0.9%
Sponsors
Minia University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
DOUBLE (Subject, Outcomes Assessor)
Eligibility
Sex/Gender
FEMALE
Age
18 Years to 35 Years
Healthy volunteers
No
Inclusion criteria
* 18-35 years old parturient with post partum headache after elective CS under spinal anesthesia with visual analog score (VAS) ≥ 4 \[14\] and Lybecker classification score ≥ 2
Exclusion criteria
* Pregnancy induced hypertension * Emergency C.S * Asthmatic candidates * Previous history of migraine or trigeminal neuralgia * History of bronchial asthma * Post partum hemorrhage * Need for GA , failed spinal anesthesia * Patient refusal
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| VAS score | pre interventiomnal, 1hour, 3 ,6, 12, 24, 34, 48, 72, 96, 120 hours | Acute pain categorization. 10= severe umimaginable pain..... 7- 9= severe pain...4-6= moderate to severe pain ..3- 5= moderate pain .... 1-3= mild pain |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Lybecker headache | pre interventiomnal,12, 24, 48, 72 hours | Severity of headache . mild, moderate , severe headache |
| number of patients in need for epidural blood patch | 5 days | VAS\>3 |
| procedure related complication | 3 days | Complications related to nebulization ( dry cough, spasm, colics......) |
| neural complications | 7 days | persistent neural complications at time of discharge |
| Trans-cranial doppler | at onset of treatment, 24, 48, 72 hours | Mean flow velocity |
| transcranial doppler | at enrollment, PREINTERVENTIONAL 24,48, 72 hours | resistive index |
Countries
Egypt
Outcome results
None listed