Authors: Alatni R I et al.
Cureus, 16(1): e52330, DOI: 10.7759/cureus.52330
Summary
This systematic review looked at treatment and prevention strategies for post-dural puncture headache (PDPH) published from 2013–2023. Using a PRISMA-style approach, the authors screened 345 publications from PubMed and ScienceDirect and included 38 studies (mostly small randomized trials plus retrospective/prospective cohorts). The paper’s big message is that PDPH management is still highly variable across institutions because the evidence base is fragmented and protocols aren’t standardized.
On prevention and medication-based treatment, the review highlights signals of benefit for oral pregabalin and IV aminophylline (both used in treatment and prophylaxis in the included studies). Other therapies described as showing favorable outcomes in parts of the literature included IV hydrocortisone, IV mannitol, a “triple prophylaxis” strategy after accidental dural puncture (epidural saline + IV cosyntropin + neuraxial morphine), and a neostigmine + atropine regimen. In contrast, neuraxial morphine alone (as prophylaxis) and epidural dexamethasone were not consistently supported.
On prevention by technique, the review reinforces the familiar needle and approach themes: smaller, non-cutting (pencil-point) needles reduce PDPH risk; repeated attempts increase risk; and patient positioning may matter (the included studies suggested lateral decubitus for spinal placement had lower PDPH than sitting, and prone positioning in some surgical contexts had lower PDPH than supine). For treatment escalation, minimally invasive nerve blocks (sphenopalatine ganglion block and greater occipital nerve block) were discussed as potentially useful options that may reduce the need for epidural blood patch in some settings, but results were mixed across studies. Epidural blood patch remains the “definitive” intervention for refractory or severe PDPH in typical clinical practice, though the review also notes variability in use and outcomes and the need to weigh invasiveness and follow-on symptoms.
Key Points
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Evidence from 2013–2023 is heterogeneous; many studies are small and institutional practices vary widely.
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The review identifies supportive evidence (not definitive guidelines) for pregabalin and IV aminophylline as options discussed for both prevention and treatment in the included literature.
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Technique still matters: smaller, non-cutting needles and minimizing multiple attempts remain among the most practical prevention steps.
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Nerve blocks (SPG and GON) are presented as less invasive options with variable evidence; epidural blood patch remains the go-to rescue therapy when conservative measures fail.
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The paper’s main gap is the need for larger, higher-quality comparative studies to standardize best-practice pathways.
What You Should Know
If you’re building a practical PDPH protocol, this review supports a stepwise approach: prevention (needle choice + minimize attempts), early conservative management (hydration/analgesics/caffeine where appropriate), consider selected pharmacologic adjuncts and/or nerve blocks based on local expertise, and reserve epidural blood patch for persistent, function-limiting PDPH or failure of medical/less invasive options. The paper also underscores that “what works” in one hospital may reflect local practice patterns more than settled science—so it’s worth standardizing internally and tracking outcomes.
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