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Is caffeine effective for the treatment of postdural puncture headache?

Clinical practice sometimes requires the use of lumbar puncture for diagnostic and therapeutic procedures. One of the complications observed in patients after lumbar puncture is performed is postdural puncture headache (PDPH).The incidence of PDPH varies between 1-30%. In most patients who experience this adverse effect, the symptoms are mild, although in some patients PDPH can be debilitating and may increase the length of hospital stay. The presence of certain predisposing risk factors increase the incidence of PDPH, such as younger adult age, needle shape and size, and patient position during the procedure. The proposed pathophysiology of spinal headache involves a complex mechanism that includes loss of cerebral spinal fluid (CSF), inability of the body to rapidly increase production of CSF, a decrease in cushion barrier for sensitive nerves, cerebral vasodilation, and an increase in cerebrospinal pressure.

The most clinically evaluated treatment option for PDPH is use of an epidural blood patch (EBP). However, this invasive procedure carries a risk of infection, seizures, back pain, and exacerbation of the headache. Other agents that have been evaluated for the treatment of PDPH include epidural administration of saline, caffeine, theophylline, sumatriptan, adrenocorticotropic hormone, dextran patch, morphine sulfate, and bed rest. Caffeine therapy is a noninvasive, safe alternative treatment for PDPH; however, caffeine has been poorly studied for this indication. The proposed mechanism of action of caffeine involves a decrease in cerebral blood flow, a reduction in cerebrospinal pressure, and cerebral vasoconstriction.

Caffeine has been FDA approved since the 1940s, and is currently available in various dosage forms. An intravenous caffeine formulation is available as caffeine sodium benzoate (CSB) and has been evaluated for treatment of PDPH. Sechzer and Abel designed a double blind, randomized, placebo-controlled study in patients with post-spinal anesthesia headaches to evaluate the effectiveness of intravenous caffeine benzoate for treatment of PDPH. The study used caffeine sodium benzoate 0.5 g/2 ml intravenously, with a second dose offered to the patients in 1-2 hours if the first dose did not alleviate spinal headache. Forty-one patients received CSB, 75% experienced relief after the first dose, and 85% of patients had spinal headache eliminated after the second dose. PDPH reoccurred in 30% of patients who received study treatment. Investigators concluded that an intravenous injection of 0.5 g CSB is effective for treatment of spinal headache. Supplemental doses may be administered at 8 hour intervals.

Jarvis et al. reported the effectiveness of a rehydration protocol in 18 patients who experienced PDPH. The regimen involved administration of 2 L intravenous hydration. The first liter contained 500 mg of CSB and was infused over 1 hour; the second liter of intravenous fluid was administered subsequently over 2 hours. In patients who required a second dose of caffeine for complete relief of spinal headache, the rehydration protocol was repeated in 4 hours. The investigators observed that in 75% of patients, PDPH was alleviated after the first or second dose of caffeine sodium benzoate. It is important to note that this is a report regarding an institutional protocol, not a designed study.

Harrington described the use of intramuscular caffeine in a case report of a 30-year-old female who developed PDPH after labor. She received 2 doses of 0.5 g of caffeine sodium benzoate intramuscularly. The first dose was administered 72 hours post labor and the second dose was given 4 hours after the first dose. Her spinal headache was completely resolved after the second dose of CSB.

Oral caffeine has also been evaluated for the treatment of PDPH in a randomized, double blind, placebo controlled clinical trial performed in 40 postpartum females. Camann et al. evaluated the administration of a single dose of 300 mg oral caffeine against placebo for treatment of spinal headaches. Caffeine was found to be more effective than placebo 4 hours after the dose was given. However, there were no differences in relief of PDPH at 24 hours between the caffeine and placebo groups.

Epidural blood patches have the most clinical evidence behind them with regards to the treatment of PDPH. Less evidence exists to support the use of caffeine for treatment of spinal headaches. The existing clinical data suggest 300 mg of oral caffeine as a single dose, or 500 mg caffeine sodium benzoate powder diluted in 1 liter of intravenous fluid and administered over 1 hour, can be effective therapeutic options for PDPH. Readministration of intravenous caffeine therapy may be considered if needed 4-8 hours after the initial dose. Further trials evaluating the use of caffeine for treatment of PDPH may bee needed to fully evaluate caffeine's efficacy as an alternative therapy.

References

Camann W, Finkelstein S. Postdural puncture headache. CNS Drugs 2000;13:15-20.

Choi A, Laurito CE, Cunningham FE. Pharmacologic management of postdural headache. Ann Pharmacother 1996;30:831-9.

Morewood GH. A rational approach to the cause, prevention and treatment of postdural puncture headache. Can Med Assoc J 1993;149:1087-93.

Sechzer PH, Able L. Post-spinal anesthesia headache treated with caffeine. Evaluation with demand method. Part I. Curr Ther Res 1978;70:729-31.

Sechzer PH. Post-spinal anesthesia headache treated with caffeine. Part II. Intracranial vascular distension, a key factor. Curr Ther Res 1978;26:440-8.

Harrington TM. An alternative treatment for spinal headache. J Fam Pract 1982;15:172,177.

Javis AP, Grenawalt JW, Fagraeus L. Intravenous caffeine for postdural puncture headache. Anesth Analg 1986;65:313-21.

Camann WR, Murray SR, Mushil PS, Lambert DH. Effects of oral caffeine on postdural puncture headache. Anesth Analg 1990;70:181-4.