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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 4  |  Page : 353-357

Comparative study between different approaches for the management of postdural puncture headache

Department of Anesthesia and Intensive Care, Faculty of Medicine, Sohag University, Sohag, Egypt

Date of Submission20-Feb-2022
Date of Acceptance26-Apr-2022
Date of Web Publication29-Dec-2022

Correspondence Address:
MD Ahmed H Hassan
Department of Anesthesia and Intensive Care, Faculty of Medicine, Sohag University, Sohag 82524
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/roaic.roaic_12_22

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Introduction The postdural puncture headache (PDPH) is one of the spinal and epidural anesthesia complications. It can be induced by using large gauge-cutting needles or performing numerous trials. Conservative treatment was the primary option for the management of PDPH, sphenopalatine ganglion block (SPGB) can be a suitable and safe option for the treatment of PDPH.
Aim The aim was to verify the efficacy and safety of transnasal SPGB using either lidocaine 2% or bupivacaine 0.5% as a treatment line for PDPH versus the conventional conservative treatment.
Patients and methods In total, 120 patients with PDPH following cesarean section under spinal anesthesia were assigned and divided into three groups. Group L (n=40) received transnasal SPGB (lidocaine 2%), group B (n=40) received transnasal SPGB (bupivacaine 0.5%), and group C (n=40) received conservative treatment for 24 h [intravenous (IV) paracetamol 1 g/8 h]. The headache severity was measured by the visual analog scale (VAS) at 0 min, 30 min, 6 h, 12 h, and 24 h post treatment.
Results No significant difference in the VAS from the baseline between the groups L and B was observed. VAS values were significantly lower in both groups when compared with patients in group C (P<0.05). No significant differences from baseline mean blood pressure, heart rate, or other complications (such as bleeding), were observed between the three groups at any timepoint.
Conclusion The headache severity in PDPH cases might be reduced more efficiently through SPGB using either lidocaine or bupivacaine, unlike other conservative treatments such as paracetamol.

Keywords: bupivacaine, lidocaine, postdural puncture headache (PDPH), transnasal sphenopalatine ganglion block (SPGB)

How to cite this article:
Hassan AH, Refaie BM, Ahmed IM, Abdelkareem AM. Comparative study between different approaches for the management of postdural puncture headache. Res Opin Anesth Intensive Care 2022;9:353-7

How to cite this URL:
Hassan AH, Refaie BM, Ahmed IM, Abdelkareem AM. Comparative study between different approaches for the management of postdural puncture headache. Res Opin Anesth Intensive Care [serial online] 2022 [cited 2023 Mar 26];9:353-7. Available from: http://www.roaic.eg.net/text.asp?2022/9/4/353/365787

  Introduction Top

Postdural puncture headache (PDPH) is a potential complication that occurs after a therapeutic or diagnostic epidural or spinal puncture [1]. It has symptoms caused by traction on pain-sensitive structures (the regions of the large arteries near the circle of Willis, the great intracranial venous sinuses, parts of the dura and dural arteries, and cranial nerves), from low cerebrospinal fluid (CSF) pressure, after a leak of CSF at the puncture site and parasympathetically mediated meningeal vessel vasodilation [1]. It causes a bilateral frontal or occipital headache that is worse in the upright posture, besides nausea, neck discomfort, dizziness, visual abnormalities, tinnitus, hearing loss, or radicular symptoms in the arm [1]. According to the International Classification of Headache Disorders, PDPH is a headache that develops after 24 h, not before and within the following 4–5 days after a dural puncture, and disappears spontaneously within 48 h up to a week after an epidural blood patch (EBP) [2]. Conservative treatment for PDPH includes bed rest, hydration, caffeine, abdominal binders, and systemic analgesics [3]. The gold standard of care for PDPH after failed conservative treatment for at least 24 h is an EBP. The efficacy rate of therapeutic EBP ranges from 68 to 90%, but risks include subdural hematoma, infection, meningitis, and delayed radicular pain [4].

Since sphenopalatine block (SPGB) is a parasympathetic ganglion in the pterygopalatine fossa that can be easily accessed through the nose [5]. After a dural puncture, parasympathetic blockade of the sphenopalatine ganglion may prevent the profound vasodilation associated with CSF leakage, so that it can provide symptomatic relief to patients [5]. SPGB has been tried as a treatment modality for PDPH with minimal drawbacks and high effectiveness [6]-[12]. SPGB is effective with migraines, cluster headaches, trigeminal neuralgia, and facial pain [5]. Transcutaneous, transoral, and transnasal methods are feasible approaches for SPGB [13],[14].

The primary objective of the current study was to verify the efficacy and safety of transnasal SPGB using either lidocaine or bupivacaine in the treatment of PDPH versus other conventional conservative measures. The secondary objectives were to study the changes in mean blood pressure (MAP) and heart rate (HR), determine the time of the first need for rescue analgesia, and the incidence of complications in the form of bleeding after SPGB application.

  Patients and methods Top

This prospective randomized study was conducted in Sohag Faculty of Medicine after the approval obtained from the local ethics and research committee and informed written consent from each patient.

Inclusion criteria

The American Society of Anesthesiologists (ASA) physical condition I–II and the patient underwent lower-segment cesarean section under spinal anesthesia. The headache developed within 5 days after the dural puncture. There is no different explanation for the headache such as personal history of migraine, stress and lack of sleep, dehydration, caffeine withdrawal, preeclampsia, cerebral venous thrombosis, meningitis, or posterior reversible leukoencephalopathy syndrome.

Exclusion criteria

SPGB in these patients may be clinically difficult or risky, coagulopathy, history of nasal bleeding, nasal polyp, septal deviation, and local anesthetics reaction were all excluded from the study.

In total, 120 patients with PDPH after cesarean section using spinal anesthesia, ages of 20–45 years old, participated in the current study. They were classified into three groups: group L (n=40) received transnasal SPGB using lidocaine 2%, group B (n=40) received transnasal SPGB using bupivacaine 0.5%, and group C (n=40) received IV paracetamol 1 g/8 h for 24 h.

Before performing SPGB, a detailed history and clinical examination were used to diagnose and rule out other possible causes of the patient’s complaint during the initial preoperative medical evaluation. A nasal decongestant was added to each nostril to avoid bleeding. Pulse oximetry, ECG, and noninvasive blood pressure were applied to all patients.

Practically, the patient’s neck was extended in a sniffing position, while the body was supine. A pillow or folded sheet under both shoulders may aid in extension. The cotton swab at the applicator’s tip was saturated with 2% lidocaine or 0.5% bupivacaine for groups L and B, respectively.

The applicator was inserted parallel to the floor of the nose, until resistance was detected, where the swab would be inserted above the middle turbinate on the posterior pharyngeal wall and left in situ for 5–10 min before being removed. The process was carried out in the other nostril. The swab does not directly contact the ganglion at this location, but the local anesthetic infiltrates the region around it via the mucous membrane covering, and the patient should notice a significant relief in their headache. Visual analog scale (VAS) was used to measure the headache severity at the presentation and after 30 min, 6, 12, and 24 h. VAS less than or equal to 3 was considered satisfactory, while patients with VAS greater than 3 in the L or the B groups are offered to receive either IV diclofenac 75 mg/12 h or a second-time SPGB block as rescue analgesia. Those with VAS greater than 3 in the C group received IV diclofenac 75 mg/12 h as rescue analgesia. MAP and HR were recorded at 30 min, 1, 2, 4, 6, 8, 10, 12, and 24 h following the PDPH therapy. Bleeding as a complication of the block was also recorded.

Statistical analysis was performed using SPSS version 24 (BMI, Armonk, New York, United States). The arithmetic mean SD, variance analysis (F-test), and χ2-test were used to analyze the data. The 5% amount was used as the significance threshold (P).

  Results Top

As shown in [Table 1], there were nonsignificant differences between the three studied groups regarding age, body mass index, and time until the appearance of headache (P>0.05).
Table 1 Demographic data

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The time-dependent changes in VAS scores are shown in [Table 2]. There was no significant difference between the group L and group B patients regarding changes in the VAS from the baseline. VAS values were significantly lower in both group L and group B patients when compared with patients in group C (P<0.01).
Table 2 Changes in visual analog score (VAS)

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HR and MAP readings were compared in all groups, as shown in [Figure 1] and [Table 3], respectively. There were no significant differences in baseline HR and MAP between the three groups at any timepoint. However, a slight increase in MAP readings was recorded in the three groups at the 24-h timepoint, compared with the baseline ([Table 3]).
Figure 1 Comparison of heart rate changes between all the study groups.

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Table 3 Comparison of mean blood pressure in mmHg (MAP) between the groups

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The time for the first need for analgesia was significantly longer in group B (215.7±7.5 min) than in groups L (210.4±7.8 min) and C (4.8±4.3 min) (P=0.006). Finally, the bleeding complications were reported for the two SPGB groups and showed that 35 patients in group L and 31 patients in group B did not exhibit any bleeding complications. Statistically, there was no difference between the two groups regarding bleeding (P=0.05).

  Discussion Top

PDPH is a complication of spinal and epidural anesthesia, which occurs because of using large gauge-cutting needles or numerous trials of punctures [15]. Because of their sex, young age, and the widespread use of neuraxial blocks, obstetric patients are thought to be at a higher risk for PDPH [16]. PDPH has the potential to cause severe morbidity in obstetric patients, even though it normally cures on its own. It can also make it difficult for the woman to care for herself or her infant, lengthen the hospital stay, or develop into a persistent headache [17].

The risk of PDPH is estimated to be up to 40% after spinal anesthesia, where it increases up to 85% after an accidental dural puncture, during epidural insertion in a pregnant woman [15]. Obstetric patients are thought to be at higher risk for PDPH due to their sex, young age, and neuraxial blocks of common use [16]. PDPH rate increases proportionally to needle diameter, ranging from 2 to 12% with a 26 G, 25% with a 25 G, and 36% with a 22 G, so, a wider gauge ‘cutting’ tipped needle or multiple spinal block trials raise the risk of a CSF leak, which are common causes of headache after a spinal procedure [18].

Staying in a supine position, sufficient hydration, analgesics, caffeine, abdominal binders, and laxatives are all suggested for PDPH conservative treatment [19]. EBP is the definite treatment for PDPH, however, it may be considered invasive and associated with complications, such as motor and sensory deficits, meningitis, Horner’s disease, hearing loss, and subdural hematoma [19]. Also, EBP can cause an unintended dural puncture, so any patient may need a second EBP if the first failed [19].

The sphenopalatine ganglion is an extracranial parasympathetic ganglion in the pterygopalatine fossa, which is positioned anterior to the pterygoid canal and posterior to the middle nasal turbinate [10]. SPGB is a minimally invasive block that was considered a PDPH therapy by preventing parasympathetic-generated vasodilation [8]. The mechanism may involve mechanical activation of the sphenopalatine ganglion, as saline (placebo) provided pain alleviation as well [5]. Kent and Mehaffey [20] found that using the sphenopalatine ganglion block (SPGB) as a first-line treatment for PDPH decreased the need for an EBP to alleviate symptoms.

Except for local nasal infections and skull-base fractures, SPGB can be performed in several ways, including transoral, subzygomatic, lateral infratemporal, and transnasal, which is the simplest and least invasive route [5],[10]-[12].

SPGB can be carried out at the bedside without imaging with rapid onset than EBP and a better safety profile [21], however, the evidence available to highlight the efficacy of the SPGB for relieving PDPH is limited and is available in the form of case reports and case series.

In this study, lignocaine and bupivacaine offered sufficient pain relief in obstetric patients with PDPH when used to perform SPGB, and those patients were pain-free for up to 24 h. The current results agree with the study conducted by Antunes et al. [22], in which SPGB was suggested as an effective first-line therapy for moderate headache in PDPH patients, who might have bilateral SPGB tested first with a backup EBP if requested.

In this study, there was a statistically significant difference in the VAS score between the two groups L and B and group C. There were no statistically significant differences in VAS values between groups L and B, which is in agreement with Puthenveettil et al. [23]. They compared the conservative treatment with diclofenac 75 mg/12 h to SPGB with 2% lignocaine and concluded that SPGB was faster and more efficient than other conservative interventions [23].

Most patients in groups L and B did not need any rescue analgesia for up to 6 h, while the later-onset pain was milder and better managed, meaning that SPGB is an effective first-line therapy for PDPH. This is in agreement with Cohen et al. [19], who reported, in their experience with 13 parturients with moderate-to-severe PDPH and treated with SPGB, that 11 of the 13 patients experienced good pain relief and did not require an EBP, whereas the other two patients were satisfied only after an EBP.

Furthermore, Patel et al. [24] examined data from 72 patients with PDPH who were divided into two groups to compare the efficacy of SPB versus EBP, and concluded that both therapies were equally successful between 24 and 48 h, however, SPGB was associated with greater headache relief at 30–60 min after treatment, where 55% of those receiving SPGB had recovered from headache 30 min after treatment compared with 21% of those receiving EBP treatment. EBP recipients, on the other hand, had a higher risk of complications, with nine people attending the emergency department, three of them had leg pain, one of them had a vasovagal reaction, and one of them had temporary hearing loss [24].

Furtado et al. [12] presented four obstetric patients with PDPH-like symptoms who had a stable and functioning SPGB within 24–48 h of the dural puncture. The SPGB provided complete pain relief in less than an hour. For one of the cases, there was no recurrence of headache, while another patient had a headache that returned after 12 h, however, it was less intense, and a second block achieved total pain relief. In the other two patients, SPGB had a 48-h efficacy. Those patients performed an EBP after 48 h, but only with partial symptomatic relief. Seven days postdural puncture, both patients were asymptomatic [12].

Kent and Mehaffey reported on their experience with three parturients diagnosed with PDPH, who were given an SPGB transnasally, and found that all three patients experienced good pain alleviation and did not require an EBP. They proposed that the method may be safely conducted in the emergency room, reducing the length of the visit, providing adequate pain management, and deferring the EBP [20].

  Conclusion Top

Because it is minimally invasive, has few complications, and offers powerful and quick analgesia, SPGB should be employed as the first strategy in the treatment of PDPH.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Plewa MC, McAllister RK. Postdural puncture headache. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2022; 260–264. Available at: https://www.ncbi.nlm.nih.gov/books/NBK430925/  Back to cited text no. 1
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Webb CA, Weyker PD, Zhang L, Stanley S, Coyle DT, Tang T et al. Unintentional dural puncture with a Tuohy needle increases risk of chronic headache. Anesth Analg 2012; 115:124–132.  Back to cited text no. 17
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Nair AS, Rayani BK. Sphenopalatine ganglion block for relieving postdural puncture headache: technique and mechanism of action of block with a narrative review of efficacy. Korean J Pain 2017; 30:93–97.  Back to cited text no. 19
Kent S, Mehaffey G. Transnasal sphenopalatine ganglion block for the treatment of postdural puncture headache in obstetric patients. J Clin Anesth 2016; 34:194–196.  Back to cited text no. 20
Schaffer JT, Hunter BR, Ball KM, Weaver CS. Noninvasive sphenopalatine ganglion block for acute headache in the emergency department: a randomized placebo-controlled trial. Ann Emerg Med 2015; 65:503–510.  Back to cited text no. 21
Antunes C, Jesus T, Ferreira S, Coutinho A, Magalhaes J. Sphenopalatine ganglion block for postdural puncture headache. J Pain Relief 2018; 7:315.  Back to cited text no. 22
Puthenveettil N, Rajan S, Mohan A, Paul J, Kumar L. Sphenopalatine ganglion block for treatment of post-dural puncture headache in obstetric patients: an observational study. Indian J Anaesth 2018; 62:972–977.  Back to cited text no. 23
  [Full text]  
Patel P, Zhao R, Cohen S, Mellender S, Shah S, Grubb W. Sphenopalatine ganglion block (SPGB) versus epidural blood patch (EBP) for accidental post-dural puncture headache (PDPH) in obstetric patients: a retrospective observation. Poster presentation at 32nd Annual Meeting of the American Academy of Pain Medicine; Palm Springs (CA); Poster #145, 2016.  Back to cited text no. 24


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  [Table 1], [Table 2], [Table 3]


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