Drug therapy for treating post-dural puncture headache.

Systematic review and meta-analysis of 13 randomized studies with 479 participants who had post-dural puncture headache after lumbar puncture or spinal or epidural procedures. Participants included adults and some children in hospital settings, with many obstetric patients; most trials were small and compared active drug treatment with placebo or conservative care.

This review evaluated multiple pharmacologic regimens for post-dural puncture headache, generally compared with placebo or conservative treatment. Active treatments included caffeine 300 mg orally as a single dose or 0.5 g IV caffeine sodium benzoate, gabapentin 900 mg/day orally for 4 days, hydrocortisone 100 mg IV every 8 hours for 48 hours or other IV dosing, theophylline 250 to 400 mg orally every 8 hours/three times daily, pregabalin 75 mg orally every 12 hours for 3 days then 150 mg every 12 hours for 2 more days, sumatriptan 6 mg subcutaneously once, and ACTH or cosyntropin 1 mg IM/IV.

Overall, caffeine showed benefit for treating post-dural puncture headache, including lower persistence of headache and reduced need for additional intervention. In one caffeine trial, headache persistence was 5/20 versus 18/21 with control (RR 0.29, 95% CI 0.13 to 0.64). Gabapentin, hydrocortisone, and theophylline reduced pain severity, and theophylline also increased the likelihood of reported pain improvement versus conservative treatment at 8 h (RR 1.95, 95% CI 1.27 to 3.01), 16 h (RR 2.25, 95% CI 1.29 to 3.92), and 24 h (RR 3.00, 95% CI 1.51 to 5.95). Sumatriptan, ACTH, pregabalin, and cosyntropin did not show clear benefit.

The evidence base was limited by small trials, heterogeneous interventions and outcomes, short follow-up, and risk of bias. Some studies had incomplete outcome reporting, and generalisability is limited because many participants were obstetric patients and several findings came from single small studies. The review authors also noted that no newer trials substantially changed the prior conclusions.