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Management and outcomes of persistent headache after accidental dural puncture in the obstetric population: A 9-year
1Clinical Research Unit in Pain Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK.
Insights
Persistent headaches after accidental dural puncture (ADP) in obstetric patients can be effectively managed with a novel pathway. Greater occipital nerve (GON) blocks offer significant, lasting relief for those unresponsive to initial treatments.
Area of Science:
- Obstetrics
- Pain Medicine
- Neurology
Background:
- Accidental dural puncture (ADP) can lead to persistent headaches (PHADP) that are disabling and challenging to treat.
- The management pathway for PHADP in obstetric patients remains unclear.
- These headaches can persist for months to years, significantly impacting quality of life.
Purpose of the Study:
- To evaluate the effectiveness and safety of a new management strategy for persistent headaches after accidental dural puncture (PHADP) in obstetric patients.
- To assess the outcomes of a novel pathway implemented in a pain medicine clinic.
- To determine the efficacy of interventions beyond initial pharmacological management.
Main Methods:
- A prospective longitudinal audit of 54 obstetric patients with PHADP treated between 2008 and 2019.
- Initial treatment included brain imaging and pharmacological agents.
- Patients unresponsive to medical management were offered greater occipital nerve (GON) blocks, followed by pulsed radiofrequency (PRF) treatment if necessary.
Main Results:
- Pharmacological management was effective in 33% of patients.
- Greater occipital nerve (GON) blocks provided durable benefit in 86% of patients who received them.
- Pulsed radiofrequency (PRF) treatment to GONs resulted in 100% durable benefit.
- Patients receiving GON treatment had significantly lower monthly headache frequency compared to other groups (p < 0.001).
Conclusions:
- A novel management pathway involving greater occipital nerve (GON) interventions is effective for persistent headaches after accidental dural puncture (PHADP) in obstetric patients.
- GON blocks and PRF treatment offer durable relief for PHADP.
- These interventions represent a valuable addition to the management of challenging post-dural puncture headaches.
Objective:
To assess the effectiveness and safety of a novel management pathway in the obstetric population presenting to a pain medicine clinic with persistent headache after accidental dural puncture (PHADP).
Background:
Accidental dural puncture (ADP) can result in headaches that persist for months to years. These headaches can be a therapeutic challenge, often cause severe disability, and management pathway remains obscure.
Methods:
Obstetric patients with PHADP referred to a pain medicine physician were prospectively followed up in a longitudinal audit of a novel management pathway. ADP reports dated from 2008 until 2019. Initial management included brain imaging and pharmacological agents. Patients who failed to respond were offered greater occipital nerve (GON) block with depot methylprednisolone followed by pulsed radiofrequency (PRF) treatment. A headache diary was completed for 4 weeks prior to commencing treatment and maintained for 24 weeks following an intervention. Data collected included use of epidural blood patch to manage postdural puncture headache, past history of headache, severity of headache, duration of persistent headache, low back pain, and employment status.
Results:
Over the 9-year period, a cohort of 54 obstetric patients with PHADP with a 16-gauge Tuohy needle were reviewed in the pain clinic. Forty patients presented with chronic daily headache (40/54, 74%). Brain imaging did not reveal any sign of intracranial hypotension in 50 patients (50/54, 93%). Mean follow-up period was 5.7 years. Two patients were lost to follow-up (2/54, 4%). Pharmacological management was effective in 17 patients (17/52, 33%). Medical management failed to improve symptoms in 35 patients (35/52, 67%), and they were offered GON block. Fourteen (14/35, 40%) patients refused the intervention. Nerve block was performed in 21 patients and produced durable benefit lasting 24 weeks in 18 patients (18/21, 86%). Three patients underwent PRF treatment to GONs and all three (100%) reported durable benefit. At final follow-up, mean monthly headache frequency was 5.9 for the medical management group, 8.6 for the refused nerve block group, and 4.1 in patients who received GON treatment (p < 0.001).
Conclusion:
ADP can cause chronic headaches that persist beyond 3 years. Interventions targeting the GONs appear to have a role in the management of PHADP.
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