Had a lovely lady return to the ED with this after having a LP the day before last...she said it felt like her head was trying to kill her from the inside out. Managed to get 2Ltr N/S in and 10mg maxolon but barely scraped the edge....the neuro guys came down and gave her 5mg endone and she was hopping....what would you guys in the states do??
Low CSF Pressure Headaches
- Thread starter BushDoc20
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IV caffeine. If that doesn't work, have anesthesia do a blood patch.
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That's actually a "Post-LP headache", not a low CSF pressure headache (that's CSF hypovolemia, or idiopathic intracranial hypotension, a syndrome, not a sequelae of an LP). Lanzarlaluna has the correct treatment, along with conservative measures such as having your patient lay completely supine for 24 hours.
so for my ED an caffine IV would be me hooking her up to a bottle of coke or giving her a long black caffine lolly to suck on....when you're in a bush hospital caffine comes in 2 forms: bottled or cup! if it came in IV i'd be having it all the time 🙂
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I reviewed prevention and management of post-LP headaches when I was in residency and was surprised to learn there is no good data to support use of caffeine--IV or oral for treatment. What really works is blood patching; if you have good anesthesia availability and they understand the literature you can save your patients many hours of discomfort by getting them patched as soon after diagnosis as possible. A lot of practitioners--fellow neurologists included--still prescribe caffeine, IV fluids, bed rest, etc. All with little to no evidence that they are any better than placebo.
Below is a copy of an article from the BMJ family that I found to be a quick and insightful read back in the day and I hope you do as well...
--woody
Myth: Fluids, bed rest, and caffeine are effective in preventing and treating patients with post-lumbar puncture headache.
Wendy Lin and Joel Geiderman
West J Med. 2002 January; 176(1): 6970.
Headache is the most common complication after lumbar puncture (LP), with reported frequency rates ranging from 6% to 36% of patients.1 August Bier (1861-1949) was the first to describe the phenomenon of post-dural puncture headache in his patients and experienced the same effect when he had the procedure performed on himself.2 Most (90%) post-LP headaches occur within 3 days of the procedure and are characteristically described as being present when the patient is in the upright position and diminished in intensity when supine.
The cause of post-LP headache is uncertain. One idea is that it is possibly due to low cerebrospinal fluid (CSF) pressure as a result of CSF leakage through a dural and arachnoid tear produced by the puncture that exceeds CSF production. The continuous decrease in CSF pressure may lead to subsequent stretching of pain-sensitive structures. Another notion is that cerebral vasodilatation, in addition to traction, is responsible for headache following LP.
Various treatments for this condition are thought to be effective, even though its cause is unclear. Many of these are implemented routinely in daily practiceincluding increased fluids, bed rest, and caffeinedespite the lack of evidence of their effectiveness.
There is no evidence supporting the use of increased fluids to prevent post-LP headache.1 The only prospective study of this intervention involved oral hydration. Dieterich and Brandt performed a prospective study of 100 age-matched, randomly allocated neurologic patients and found no correlation between the incidence of post-LP headache and the amount of fluid intake.3 Half of the patients were asked to drink 1.5 L of fluids per day during the 5 days after an LP, and the other half was asked to drink 3.0 L of fluids per day for the same period. The intensity of the headache was classified into four grades according to the severity and onset of symptoms after getting up from the LP. The proportion of symptom-free individuals was 64% in both groups of patients; therefore, the incidence of post-LP headache is independent of fluid intake.
Another commonly held belief is that bed rest or various body positions after LP reduce the incidence of post-LP headache compared with immediate ambulation. But Carbaat and van Crevel performed a controlled prospective study that showed that no benefit was found with 24 hours of bed rest in preventing the headache.4 A diagnostic LP was performed in 100 neurologic patients by one investigator. Half of the patients were immediately mobilized, and the other half had bed rest. To account for the possibility of improved technique by the same investigator with successive LPs, the first 25 were immediately mobilized, the next 50 were given bed rest, and the last 25 were immediately mobilized. Follow-up was for 7 days, and no significant differences were found between the two groups. Other similar studies have confirmed these findings.
Oral and intravenous administration of caffeine has been recommended as a therapeutic option for post-LP headache, often as an effort to avoid using the more invasive treatment of epidural blood patching. The presumed mechanism is thought to be increased cerebral arterial vasoconstriction, resulting in decreases in cerebral blood inflow and blood volume in the brain. No well-designed, adequately powered, randomized controlled studies have been performed to prove the effectiveness of caffeine. Published information on this therapy comes from case reports or reviews that cite one study in 1975.5 The investigators in that study used a double-blind demand method to evaluate the intravenous administration of caffeine sodium benzoate in 41 patients for whom treatment with more conservative measures had failed. This study was limited in that the study size was small, it did not control for known risk factors such as sex and age, it did not include patients undergoing diagnostic LPs, and it did not investigate or correlate the quantity of daily caffeine intake before the LP was performed. In addition, the placebo arm of the study crossed over into the treatment arm. Given these limitations of the one study that is consistently cited, the evidence supporting the use of caffeine in treating post-LP headache remains weak.
Table 1
Effective measures for preventing and treating post-LP headache
Prevention
Needle size: Halpern and Preston7
Bevel direction: Flaatten et al8
Stylet replacement: Strupp et al9
Treatment
Epidural blood patch: Safa-Tisseront et al10
Factors that have been shown to be associated with post-LP headache include needle size, bevel orientation, and replacement of the stylet before withdrawing the needle (box).1,7,8,9,10 Articles in the anesthesia literature have suggested that needle design is also associated, but the data in articles on diagnostic LP are conflicting and have been inadequate to assess this factor. When headache does occur, epidural blood patching had been effective in 85% to 98% of patients and is indicated for those with moderate to severe headache for more than 24 hours.2 It is performed by slowly injecting 10 to 20 mL of the patient's blood into the lumbar epidural space at the same interspace or the interspace below the previous puncture. Although it might be intuited that epidural blood patching relieves post-LP headache by tamponading the dural hole through a mass effect, the actual mechanism of action is unclear.6
CONCLUSION
Post-LP headache remains a vexing problem that is not well understood. In attempting to prevent or treat this phenomenon, physicians should be aware that there is no evidence to support treatment with fluids and bed rest and that the evidence supporting the use of caffeine is poor.
​
References
1. Evans RW, Armon C, Frohman EM, Goodin DS. Assessment: prevention of post-lumbar puncture headaches: report of the therapeutics and technology assessment. subcommittee of the American Academy of Neurology. Neurology 2000;55: 909-914. [PubMed]
2. Evans RW. Complications of lumbar puncture. Neurol Clin 1998;16: 83-105. [PubMed]
3. Dieterich M, Brandt T. Incidence of post-lumbar puncture headache is independent of daily fluid intake. Eur Arch Psychiatry Neurol Sci 1988;237: 194-196. [PubMed]
4. Carbaat PA, van Crevel H. Lumbar puncture headache: controlled study on the preventive effect of 24 hours' bed rest. Lancet 1981;2: 1133-1135. [PubMed]
5. Sechzer PH, Abel L. Post-spinal anesthesia headache treated with caffeine: evaluation with demand methodpart I. Curr Ther Res 1978;24: 307-312.
6. Fernandez E. Headaches associated with low spinal fluid pressure. Headache 1990;30: 122-128. [PubMed]
7. Halpern S, Preston R. Postdural puncture headache and spinal needle design: metaanalyses. Anesthesiology 1994;81: 1376-1383. [PubMed]
8. Flaatten H, Thorsen T, Askeland B, et al. Puncture technique and postural postdural puncture headache: a randomised, double-blind study comparing transverse and parallel puncture. Acta Anaesthesiol Scand 1998;42: 1209-1214. [PubMed]
9. Strupp M, Brandt T, Muller A. Incidence of post-lumbar puncture syndrome reduced by reinserting the stylet: a randomized prospective study of 600 patients. J Neurol 1998;245: 589-592. [PubMed]
10. Safa-Tisseront V, Thormann F, Malassine P, et al. Effectiveness of epidural blood patch in the management of post-dural puncture headache. Anesthesiology 2001;95: 334-339. [PubMed]
Below is a copy of an article from the BMJ family that I found to be a quick and insightful read back in the day and I hope you do as well...
--woody
Myth: Fluids, bed rest, and caffeine are effective in preventing and treating patients with post-lumbar puncture headache.
Wendy Lin and Joel Geiderman
West J Med. 2002 January; 176(1): 6970.
Headache is the most common complication after lumbar puncture (LP), with reported frequency rates ranging from 6% to 36% of patients.1 August Bier (1861-1949) was the first to describe the phenomenon of post-dural puncture headache in his patients and experienced the same effect when he had the procedure performed on himself.2 Most (90%) post-LP headaches occur within 3 days of the procedure and are characteristically described as being present when the patient is in the upright position and diminished in intensity when supine.
The cause of post-LP headache is uncertain. One idea is that it is possibly due to low cerebrospinal fluid (CSF) pressure as a result of CSF leakage through a dural and arachnoid tear produced by the puncture that exceeds CSF production. The continuous decrease in CSF pressure may lead to subsequent stretching of pain-sensitive structures. Another notion is that cerebral vasodilatation, in addition to traction, is responsible for headache following LP.
Various treatments for this condition are thought to be effective, even though its cause is unclear. Many of these are implemented routinely in daily practiceincluding increased fluids, bed rest, and caffeinedespite the lack of evidence of their effectiveness.
There is no evidence supporting the use of increased fluids to prevent post-LP headache.1 The only prospective study of this intervention involved oral hydration. Dieterich and Brandt performed a prospective study of 100 age-matched, randomly allocated neurologic patients and found no correlation between the incidence of post-LP headache and the amount of fluid intake.3 Half of the patients were asked to drink 1.5 L of fluids per day during the 5 days after an LP, and the other half was asked to drink 3.0 L of fluids per day for the same period. The intensity of the headache was classified into four grades according to the severity and onset of symptoms after getting up from the LP. The proportion of symptom-free individuals was 64% in both groups of patients; therefore, the incidence of post-LP headache is independent of fluid intake.
Another commonly held belief is that bed rest or various body positions after LP reduce the incidence of post-LP headache compared with immediate ambulation. But Carbaat and van Crevel performed a controlled prospective study that showed that no benefit was found with 24 hours of bed rest in preventing the headache.4 A diagnostic LP was performed in 100 neurologic patients by one investigator. Half of the patients were immediately mobilized, and the other half had bed rest. To account for the possibility of improved technique by the same investigator with successive LPs, the first 25 were immediately mobilized, the next 50 were given bed rest, and the last 25 were immediately mobilized. Follow-up was for 7 days, and no significant differences were found between the two groups. Other similar studies have confirmed these findings.
Oral and intravenous administration of caffeine has been recommended as a therapeutic option for post-LP headache, often as an effort to avoid using the more invasive treatment of epidural blood patching. The presumed mechanism is thought to be increased cerebral arterial vasoconstriction, resulting in decreases in cerebral blood inflow and blood volume in the brain. No well-designed, adequately powered, randomized controlled studies have been performed to prove the effectiveness of caffeine. Published information on this therapy comes from case reports or reviews that cite one study in 1975.5 The investigators in that study used a double-blind demand method to evaluate the intravenous administration of caffeine sodium benzoate in 41 patients for whom treatment with more conservative measures had failed. This study was limited in that the study size was small, it did not control for known risk factors such as sex and age, it did not include patients undergoing diagnostic LPs, and it did not investigate or correlate the quantity of daily caffeine intake before the LP was performed. In addition, the placebo arm of the study crossed over into the treatment arm. Given these limitations of the one study that is consistently cited, the evidence supporting the use of caffeine in treating post-LP headache remains weak.
Table 1
Effective measures for preventing and treating post-LP headache
Prevention
Needle size: Halpern and Preston7
Bevel direction: Flaatten et al8
Stylet replacement: Strupp et al9
Treatment
Epidural blood patch: Safa-Tisseront et al10
Factors that have been shown to be associated with post-LP headache include needle size, bevel orientation, and replacement of the stylet before withdrawing the needle (box).1,7,8,9,10 Articles in the anesthesia literature have suggested that needle design is also associated, but the data in articles on diagnostic LP are conflicting and have been inadequate to assess this factor. When headache does occur, epidural blood patching had been effective in 85% to 98% of patients and is indicated for those with moderate to severe headache for more than 24 hours.2 It is performed by slowly injecting 10 to 20 mL of the patient's blood into the lumbar epidural space at the same interspace or the interspace below the previous puncture. Although it might be intuited that epidural blood patching relieves post-LP headache by tamponading the dural hole through a mass effect, the actual mechanism of action is unclear.6
CONCLUSION
Post-LP headache remains a vexing problem that is not well understood. In attempting to prevent or treat this phenomenon, physicians should be aware that there is no evidence to support treatment with fluids and bed rest and that the evidence supporting the use of caffeine is poor.
​
References
1. Evans RW, Armon C, Frohman EM, Goodin DS. Assessment: prevention of post-lumbar puncture headaches: report of the therapeutics and technology assessment. subcommittee of the American Academy of Neurology. Neurology 2000;55: 909-914. [PubMed]
2. Evans RW. Complications of lumbar puncture. Neurol Clin 1998;16: 83-105. [PubMed]
3. Dieterich M, Brandt T. Incidence of post-lumbar puncture headache is independent of daily fluid intake. Eur Arch Psychiatry Neurol Sci 1988;237: 194-196. [PubMed]
4. Carbaat PA, van Crevel H. Lumbar puncture headache: controlled study on the preventive effect of 24 hours' bed rest. Lancet 1981;2: 1133-1135. [PubMed]
5. Sechzer PH, Abel L. Post-spinal anesthesia headache treated with caffeine: evaluation with demand methodpart I. Curr Ther Res 1978;24: 307-312.
6. Fernandez E. Headaches associated with low spinal fluid pressure. Headache 1990;30: 122-128. [PubMed]
7. Halpern S, Preston R. Postdural puncture headache and spinal needle design: metaanalyses. Anesthesiology 1994;81: 1376-1383. [PubMed]
8. Flaatten H, Thorsen T, Askeland B, et al. Puncture technique and postural postdural puncture headache: a randomised, double-blind study comparing transverse and parallel puncture. Acta Anaesthesiol Scand 1998;42: 1209-1214. [PubMed]
9. Strupp M, Brandt T, Muller A. Incidence of post-lumbar puncture syndrome reduced by reinserting the stylet: a randomized prospective study of 600 patients. J Neurol 1998;245: 589-592. [PubMed]
10. Safa-Tisseront V, Thormann F, Malassine P, et al. Effectiveness of epidural blood patch in the management of post-dural puncture headache. Anesthesiology 2001;95: 334-339. [PubMed]
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That wonderful!! But here is the crap I get from anesthesia
"Ugh, yeah, well um, send them to the ER (to wait 8 hours to be seen) and ask them to give IV caffeine, and if that don't work, then send them to the ER again (to again wait hours to be seen) so they can call me and maybe I'll do a blood patch. Oh by the way, I am in the OR and some patient in the PACU won't wake up. I didn't actually go a examine them, do labs, imaging, or even call the surgeon responsible, yah think you can go have a peak at them and tell me whats wrong with 'em"
Okay,my saracasm is off. We all know that blood patching is the preferred treatment, but as I just showed, sometimes getting anesthesia to do one is not easy.
"Ugh, yeah, well um, send them to the ER (to wait 8 hours to be seen) and ask them to give IV caffeine, and if that don't work, then send them to the ER again (to again wait hours to be seen) so they can call me and maybe I'll do a blood patch. Oh by the way, I am in the OR and some patient in the PACU won't wake up. I didn't actually go a examine them, do labs, imaging, or even call the surgeon responsible, yah think you can go have a peak at them and tell me whats wrong with 'em"
Okay,my saracasm is off. We all know that blood patching is the preferred treatment, but as I just showed, sometimes getting anesthesia to do one is not easy.
lol, Radiologists do it here! and they wouldn't blood patch her for 6hrs ...twits! so i made up a pot of black crappy coffee...strong, no milk no sugar and told her very nicely i would like that entire pot of very crappy coffee gone in 3hrs....fixed her up good and proper....she was skipping out the ED doors! the Radiographer who specialises in intervention came to have a look at her and asked me where she went my reply '' out that door sunshine and home to bounce off the walls coz you lot wouldn't bloodpatch her for 6hrs for i gave her crappy coffee..."
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Thanks for the article- I always feel like residents come up with good stuff in training for their departments that should get out of their individual departments but usually don't, the kind of stuff that's not really journal level as far as it's more of a lit review but still useful.
