Epidural Blood Patch: A Headache Cure that Hits the Spot!
Abstract & Commentary
By Dara G. Jamieson, MD, Associate Professor of Clinical Neurology, Department of Neurology and Neuroscience, Weill Medical College, Cornell University. Dr. Jamieson reports that she is a retained consultant for Boehringer Ingelheim, Merck, and Ortho-McNeil; and is on the speaker's bureau for Boehringer Ingelheim and Merck. This article originally appeared in the June 2008 issue of Neurology Alert. It was edited by Matthew Fink, MD, and peer reviewed by M. Flint Beal, MD. Dr. Fink is Vice Chairman, Professor of Critical Care Neurology, NewYork-Presbyterian Hospital, and Dr. Beal is Professor and Chairman, Department of Neurology, Cornell University Medical College. Drs. Fink and Beal report no financial relationships relevant to this field of study.
Synopsis: Epidural blood patch is an effective treatment for post dural puncture headache.
Source: van Kooten F, et al. Epidural blood patch in post dural puncture headache: a randomised, observer-blind, controlled clinical trial. J Neurol Neurosurg Psychiatry 2008; 79:553-558.
Use of a small-bore, non-cutting needle decreases the frequency of post-dural puncture headache, a persistent positional headache that is common in young women who develop a headache after lumbar puncture. A post-dural puncture headache may complicate up to 40% of spinal taps and can be functionally disabling for days to weeks.
Since its introduction in the 1960s, the epidural blood patch has been used to treat post-dural puncture headaches; however, controversy remains about its indications, efficacy, and mechanism of action. This randomized, controlled clinical trial compared the efficacy of an epidural blood patch to conservative treatment of post-dural puncture headaches. Of 285 patients who underwent a diagnostic lumbar puncture, about 20% developed a moderate-to-severe headache between 24 hours to a week later. Patients randomized to active treatment received an epidural blood patch using the "loss of resistance" technique to place the needle, through which 15-20 mL of venous blood was injected, into the epidural space. Conservative treatment consisted of bed rest for 24 hours while drinking at least 2 L of fluid a day. The primary outcome was the presence of a headache (classified on a 4-point pain and functional impairment scale) 24 hours after the start of treatment. Associated headache symptoms also were assessed. The headache symptoms at 24 hours, and the patient's sense of well being at 7 days, were assessed via a telephone interview by a research nurse who was blinded to treatment. Randomization resulted in more patients with a history of recurrent headache being treated with conservative treatment. The primary outcome, a headache occurring a day after the treatment, occurred in 11 out of 19 (58%) patients who were treated with epidural blood patch, compared to 19 out of 21 (90%) patients treated conservatively (P = 0.03). The headaches 24 hours after treatment were consistently milder in the epidural blood patch-treated patients, as compared to conservatively-treated patients. A week after treatment randomization, headache was still present in 3 (16%) patients treated with the epidural blood patch; however, headache was persistent for a week in 18 (86%) patients treated with only rest and fluids (P < 0.001). Almost half of the patients treated conservatively still had a moderate-to-severe disabling headache a week after treatment. The patients with post-dural puncture headache, who were treated with an epidural blood patch, enjoyed a more rapid and more complete relief than did conservatively-treated patients. Treatment with an epidural blood patch did not result in any more complications than did conservative treatment.
Commentary
van Kooten and colleagues concluded that an epidural blood patch is an effective treatment for post-dural puncture headache, offering rapid and complete resolution of headache symptoms in most patients. They suggest repeating the procedure for refractory patients. Some limitations of this relatively small study must be considered; patients were not blinded with sham treatment procedures. More patients with a recurrent headache history in the conservatively-treated group could result in increased propensity for headaches in general. However, the outcomes of this study should encourage the more frequent use of an epidural blood patch, which may offer relief by compressing the epidural space with an increase in spinal pressure, or by promoting inflammation and healing of the dural tear.
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