Although uncommon, severe headaches, neck sitffness, and other symptoms may occur after epidural procedures (lumbar puncture). Join host, Geoff Wall, as he evaluates new guidelines for the management of these symptoms
Post procedural headache can be severe and last up to two weeks or longer. Management includes standard pain medications but may require caffeine or application of a blood patch to prevent dural leak.
Geoff Wall, PharmD, BCPS, FCCP, BCGP
Professor of Pharmacy Practice, Drake University
Internal Medicine/Critical Care, UnityPoint Health
Uppal V, Russell R, Sondekoppam R, et al. Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report. JAMA Netw Open. 2023;6(8):e2325387. doi:10.1001/jamanetworkopen.2023.25387
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Upon successful completion of this knowledge-based activity, participants should be able to:
1. Discuss with patients the risk factors and symptoms of post-procedural headache
2. Discuss pain management strategies for post-procedural headache
0.05 CEU/0.5 Hr
Initial release date: 9/18/2023
Expiration date: 9/18/2024
Additional CPE details can be found here.
Welcome to the Game Changers podcast, where we have clinical conversations that impact your pharmacy practice. Let's listen in as our team discusses this week's clinical practice game changer.Speaker 2:
Hello and welcome again to Game Changers clinical conversations. I am Jeff Wall, your host. I am a professor of pharmacy practice at Drake University and internal medicine clinical pharmacist at Iowa Methodist Medical Center. Welcome to the show. So today we are again going to kind of go off the beaten path, but I thought this was pretty interesting. It is a brand new guidelines for the management of post procedural headaches. So people who have epidural procedures done and they develop a pretty bad headache afterwards and these are the first official guidelines on the management prevention of that just published a couple of weeks ago in JAMA open network. And again, this isn't realizing. This is not a huge primary care thing, but I will tell you that certainly in my practice over the years I've certainly seen this several times and probably I see it three or four times a year where someone will get an epidural for pain. An obstetric patient will get epidural anesthesia. In my world it's usually someone who gets a lumbar puncture and then after the lumbar puncture they develop this just absolute blinding headache and I've heard people say it's just the worst headache they've ever had, and so how to deal with that and how to prevent it and how to manage it is something that I deal with several times a year and if you work in patients, something you're probably going to see as well. So when this crossed my desk I was like wow, I mean, this is the first guidelines ever on that. I thought it was definitely worth kind of reviewing. So again, we're talking about post procedural puncture headache, or PDPH, which is a recognized complication of epidural procedures. And it happens because they're unintentional, durable puncture right, so they get into the epidural space, but unfortunately they puncture the, the dural space below that, and that leads to a drop in CSF pressures, which they suspect is the cause of the headache, though, interestingly, studies have found that even when they, when they measure CSF pressures in these patients, that that there is some new, much of a correlation between drop and CNF pressures and the development of headache. But that's generally thought to be the path of physiology. So these guidelines are pretty extensive and again, if you're not in primary care or you're one of the one of the OBGYN people who who listen to us or anesthesia people listen to us, it's, it's definitely worth a read. They pretty much got approval from every possible major organization that could possibly deal with this, including the American Society of Regional Anesthesia and Pain Medication, the European Society of Regional Anesthesia and Pain Therapy, the Society for Obstetric Anesthesia and Parenatology, the Obstetric Anesthesis Association, the American Society of Spine Radiology and the American Interventional Headache Society. I haven't even heard of most of those organizations, I mean. So I have to bet I was like, okay, well, I mean they certainly talk to everybody who who probably would have an opinion on this, and they basically got input from all of these organizations and they actually reviewed the guidelines and put their stamp of approval on this. But yeah, I have to bet I you have to wonder what the annual meeting of the American Interventional Headache Society is like. Do they have, like what, six people there? And so I don't know, it's just it's pretty interesting, but anyway. They then talk about the definition. So the definition by the International Headache Society yet another organization is that PDPH is a headache contributed to low cerebral spinal fluid pressure occurring within five days of a epidural procedure or a lumbar puncture caused by CSF leakage through the dural space, and they note that the headache is usually accompanied by neck stiffness, often with subjective hearing symptoms, and I've heard I've seen that a couple of times too where patients complain of being able to read, about ringing in their ears or sometimes a loss of hearing, a subjective loss of hearing in one ear or the other. It's usually remits within two weeks after the puncture, but sometimes does not. And something I was unaware of just because either I haven't seen it or that these patients go home and develop long-term problems is that many patients actually have remitting headaches after that two weeks and it can be again extreme in severity, at least on a par with migraine pain and sometimes worse and that they note that there's some complications that it reported with post-procedural headache, including backache, cranial nerve dysfunction, subdural hematoma and cerebral venous sinus thrombosis. And again, I've never seen any of those type of complications. But doing some research prior to this podcast, I mean it is uncommon, but it has been reported all of those things have. So post-procedural headache has the potential to have some serious long-term side effects and even if you just say, well, it's only gonna last two weeks, that's not that big of a deal. Keep in mind that the patients who may suffer from this the most are postpartum patients, and trying to take care of a little one while you've got a terrible headache that you can barely think straight for two weeks is not going to be fun, right? So, for a variety of reasons, this isn't something that should be shrugged off as, oh well, this is just one of those things that happens with epidurals. You're just gonna have to deal with it. So, again, I had been completely unaware of the long-term complications associated with this, so that was kind of interesting. As far as the methodology of the guidelines, it's pretty standard. They used, instead of the grade guidelines, they used the squire guidelines, which I had heard of before, but it's not really the standard. But I mean it certainly can be used. It stands for standards of quality improvement, reporting, excellence. Again, it has very similar requirements to the grade guidelines, where you're required to basically reach consensus in a group that you make all your recommendations based on the evidence and you assess the evidence by how robust the evidence is and by how high the recommendation is based on that evidence. So again, just like almost all other guidelines nowadays, it's a PICO format where they ask questions and try and answer the question based on evidence. The evidence is graded as A, b, c or D, again on a high level of evidence, and the certainty is high, moderate or low. They brought all that together and then made the recommendation and basically the level of certainty of that recommendation. Basically, as you might imagine, there's not a ton of randomized control trials on this, though there are some. So a lot of the evidence to support the recommendations isn't as robust as you might think but surprisingly, considering all the different groups involved, they found 90 to 100% consensus for almost all recommendations after the second round of voting. So it's kind of interesting. So we talked about the definition of what the post-procedural headache is. It's again worth noting that, even though we think that this is because of a drop in pressure in the CSF due to a durable puncture, that again they have not found significant differences between pressures after the level of headache. So again, that may or may not be the pathophysiologic reason that applies. So the first question that they ask is when should post-procedural headache be suspected? And they note that it should be suspected if you have a headache or these other neurological symptoms the backache, the neck stiffness, the hearing stuff within five days of a neural axle procedure, which a level of certainty was moderate. They say one of the key notes in especially the headache is that the headache gets better when people are lying flat, which I guess kind of stands for reason because that's going to obviously change the cerebral spinal fluid pressure. So if they have kind of an orthostatic response to the headache when they stand up or sit up the headache gets a lot worse. That should be kind of a cardinal thing for diagnosis of this. And patients who develop this again because of the possible long-term complications shouldn't just shrug it off. They really should at least report it to their physician who performed the procedure. They note that they have done some studies taking a look at risk factors. So again, I suspect if you were an anesthesiologist and you were performing the neural axle procedure, you would want to take special care in patients who are at risk. And they note that with a high level of certainty. Age is actually one of the biggest risk factors and interestingly, younger age is associated with an increased risk of post-procedural headache. Of course you have to wonder, since the vast majority of neural axle procedures are done on obstetric cases, that is that the reason we just do far more neural axle procedures in pregnant women, so they're the ones who are more likely to get it. But again, the guidelines note that younger age is associated with it. As you might again guess, female sex is associated with increased risk of post-procedural headache and again one would wonder if that's just because pregnant women get more neural axle procedures. They does not suggest, surprisingly to me, that body mass index. So obesity. You would think that as obesity goes up it may be more difficult for anesthesiologists to perform neural axle procedures without perhaps nicking the dura. I know that in my hospital when we have an obese patient who requires a lot more puncture, we rarely do that without getting them down to interventional radiology. So they can actually do imaging to make sure that you do get a decent LP done. So I thought that was actually kind of interesting that BMI actually is not associated with an increased risk of post-procedural headache. Other comorbidities patients who have a history of migraine or other severe headache are at higher risk of developing post-procedural headache. Smoking does might be associated with it. The level of certainty of the evidence is fairly low. Depression does not appear to be a risk factor for post-procedural headache. And again, as you might imagine, that post-procedural headache and an active pushing during the second stage of labor has been studied. I wouldn't have guessed that, but apparently is conflicting whether putting in the epidural needle at that point of labor is associated with an increased risk. I guess that's again kind of stands for reason. Difficult to do an epidural who's someone who's actively in labor and actively pushing. You might be at more risk for nicking the dura when you do that. So kind of interesting I thought. So that's kind of the definition, that's kind of the risk factors. What can we use to prevent post-procedural headache? And from the internal medicine perspective Because again we're not going to focus on what the anesthesiologist can do to prevent or treat post-procedural headache what can we do as far as treatment is concerned? We're going to talk about all that after a message from our sponsor CE.Speaker 1:
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So we're back talking about a unique set of guidelines, guidelines talking about the prevention and treatment of post-patriotal headache that was published in JAMA Omen Network just a couple of weeks ago. We've talked about the definition, we've talked about risk factors. Now what can we do to prevent and treat? So first we'll talk about treatment. Again, as far as prevention is concerned, there are all sorts of techniques that the anesthesiologist can try to do to minimize the risk. Since this isn't an anesthesiologist podcast, it's really beyond the scope of what we're going to talk about here. So, yes, if you want to read that section of the guidelines, as always we have a link to the guidelines in our show notes. You might want to read that, but again, I would suspect most of our audience that's going to be not something that they do so we're going to focus on management, and as far as management is concerned, you would think that bed rest would be the way to go, because if they feel better when they're lying down, we should try and keep them lying down as much as possible. They say. Though, although this might be a temporizing measure for symptomatic relief, you actually probably don't want them to be plowed on their back for long periods of time. This is certainly true for obstetric patients, right? We want them to get up and move around so that they're at decreased risk of being a strong embolism, and you should just get them around and move anyway. So they say that, yes, for temporizing a symptomatic relief, we should do that, but we should not order long-term bed rest in these patients. Second, we should make sure that they're adequately hydrated. When people have really bad headaches, of course, it's hard for them to get proper hydration and fluids in. So, again, oral fluids are certainly reasonable for an outpatient, but intravenous fluid should be used if a patient can't maintain normal hydration. They've tried things like abdominal binders to see if that increases CSF pressure. That doesn't seem to be beneficial. Apparently, somebody has studied aroma therapy. Wouldn't have guessed that for post-procedural headache and shocking news it doesn't seem to be effective for that either. So no aroma therapy, I suppose, for that. Then they talk about actual analgesia for these patients. Like everything else, multimodal analgesia with things like acetaminophen, non-stroidal, should be offered to all patients with post-procedural headache, unless it's contraindicated. That's evidence grade B. They do say that short-term use of opioids could be considered. I know in my cases that I've seen in past we've really tried to avoid opioids in these patients just because we know it's temporary. Usually we can get at least some relief with non-opioid therapies, but certainly if somebody had a severe headache and traditional non-opioid therapies wouldn't work, yes, I think a PRN order for the short-term kind of makes sense. They of course don't recommend long-term opioids, because who does recommend long-term opioids for most types of pain anymore? They do go into some detail, talking about the one treatment that I've used many times over the years I know it's been studied is caffeine. Caffeine seems to be fairly effective in relieving post-procedural headache and should be offered according to the guidelines within the first 24 hours to a maximum dose of 900 milligrams a day. They do note much less caffeine 200 to 300 milligrams a day of breastfeeding, they say instead of drinking 10 cups of coffee, try to do one source of caffeine to prevent adverse effects. Basically, and talking about caffeine, in the old days, when we had somebody with when a post-hap headache, we would just give them intravenous caffeine, which, yes, does exist. Well, it used to exist. Now it actually is not in most cases available, and when? it is available, it's limited to use in the neonatal intensive care unit. So most hospitals do not have it available for adults or don't have it available at all. So you know again, in the old days we used to give 500 milligrams to 1000 milligrams of IV caffeine. Now you're going to be kind of stuck giving you know oral method of caffeine. It's worth noting that the average cup of coffee has somewhere between 1500 milligrams of caffeine in it. If you're using very potent, you know high caffeine things like energy drinks and stuff like that, you might be able to get up to 200 milligrams. So you know it's going to require, you know, either taking caffeine tablets, which do exist, or, you know again, having some pretty potent drinks, including caffeine, to really get that treatment. So in the last 10 years or five years or so, I've had a difficult time, you know, getting caffeine to these patients just because IV caffeine doesn't exist anymore. And if you've got a terrible headache, drinking, you know, five lattes is not something you're really interested in doing at that second. So that has been a struggle that I've had over the years. Then after that they've tried all sorts of other things. They've tried hydrocortisone, the ophthalene, triptans, which I thought triptans might have an effect, but they don't. Neostigmine atropine, on and on and on and on Gabapentin, because of course, who hasn't tried Gabapentin for some pain syndrome somewhere? And none of them have found that they're beneficial. So none of those things should be recommended for the treatment of post-procedural headaches. So then, if those conservative measures fail, then you can move on to procedural interventions. They've tried all sorts of different procedural interventions for the treatment of post-procedural headache and unfortunately most of them have not been very effective. They say that using a occipital nerve block with wider gauge needles may be beneficial, but the benefit is uncertain. They also say that epidural saline may be a temporary benefit, because I'm sure it just increases CSF pressures temporarily. And they actually caution against the use of fiber and glue to basically seal the dural leak, because it's been associated with anaphylaxis and aseptic meningitis. So yeah, probably don't want to do that. And then they talk about the wide variety of other procedures that have been done. Acupuncture has been tried, it doesn't work. A number of other anesthetic or anesthesia procedures, including ganglion blocks, occipital nerve blocks, things like that. They note that some of these can be offered to patients but either don't have a lot of headache or don't have a lot of evidence to support them or the benefit is really kind of temporary. They note that using repeat spinal anesthesia with a smaller needle may have some benefit but really is only used in small cases. It doesn't support. Other types of drugs like. Epidural morphine shouldn't be used, and then a variety of, again, epidural dextran, gelatin starch. All this other stuff doesn't seem to be beneficial. So really, the big procedure that should be done in these patients, of course, is the epidural blood patch, which I've seen done many, many times in these patients. So if conservative therapies don't work, the anesthesiologist goes in and basically seals the dural leak with an epidural blood patch. As I understand it, it's not a very difficult procedure to do. It's obviously not something that I'm going to be doing anytime soon, but the people I've been asked these y'all just talked to over the years, or the residents I've talked to over the years seems that it's a fairly simple procedure. However, it does have risks, especially in patients who have a risk of bleeding, because, again, the point of this is to basically cause a small blood leak that basically clots over the dural puncture. But if the patient's at risk of bleeding, they're at risk of epidural hematomas, which can be actually not life-threatening but can lead to permanent paralysis. So, even though blood patches are safe and effective in the vast vast majority of patients, there are patients you would not want to use an epidural blood patch, and that's in patients who have a platelets list of 70,000, according to the guidelines, in patients who are taking antiplatelet agents or aniquagulants. It basically says that the risk is there. And again, it doesn't mean it's an absolute contraindication which you need to be very careful about using doing epidural blood patches in patients on those medications. So it doesn't go so far as to say, yes, you absolutely shouldn't use these, but they just basically reiterate throughout the guidelines that caution should be used in these patients because of the increased risk of spinal hematoma. Is imaging required in these patients? Do you have to run them to the MR or something like that? They say largely no, that once you've kind of figured out the diagnosis, especially if they have orthostatic headache, that you probably don't need an extensive imaging workup. But they do note that if the patient has had a headache onset more than five days after the procedure, then it's less likely to be post-procedural headache and that's something you'd want to consider. If they have any focal neurologic defects, visual changes, alteration and consciousness or seizures, especially in the post-partum period, that should prompt neuroimaging to evaluate other diagnoses. But again, we would do that and everybody who came in with new onset focal deficits, visual changes, alteration and consciousness or seizures right? So everybody who hits the emergency room with any new onset effects like that are all going to get neuroimaging and at a minimum a CT scan, as you might imagine. So that's kind of it, that's kind of the guidelines and basically I think the piece to take away from the primary clinician is that if a patient has had a neural actual procedure and they come to you instead of the person who did the procedure and say, hey, I've had this headache for four or five days. It started the day after I got the neural actual procedure and it hasn't been going away what should you do? I mean, I think the first question you ask is are they having any other problems? Are they having hearing loss? Are they having neck stiffness? Are they having focal deficits? Are they having anything along those lines? I think they should contact the physician who actually did the procedure to see what the next move is. If, in the hospital, these patients have a post-procedural headache, it's reasonable to try multimodal therapy, occasionally opioids, try to get caffeine into them to see if that works in the first 24 hours. But if all else fails, then yes, if they don't have any contraindications, get anesthesiology and to perform a blood patch, and that usually works in the vast majority of patients. So that's it for this week of Game Changers. A little bit off the beaten path but hopefully something you enjoyed. We will see you next week, but until then, remember time flies. I don't know where it's going, but the most important day is today. We will see you next time, Jen here.Speaker 1:
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