DISCUSSION
A thorough history and physical examination, as well as the clinical
presentation (with documented Dural puncture and acute postural headache
being the most distinctive features), are used to make the diagnosis of
PDPH. An intracranial pathology such as an intracranial subdural
hematoma and posterior reversible encephalopathy syndrome are included
in the differential diagnosis of PDPH in an obstetric patient, along
with caffeine withdrawal, headaches, meningitis, sinus-related
conditions, preeclampsia, pneumocephalus, and
meningitis.4
The International Headache Society (IHS) defines PDPH as a headache
occurring within 5 days of a lumbar puncture, caused by cerebrospinal
fluid (CSF) leakage through the dural puncture. It is usually
accompanied by neck stiffness and/or subjective hearing symptoms within
two weeks; the PDPH typically goes away on its own or after the leak has
been sealed with an autologous epidural lumbar
patch.5
Treatment options can be divided into conservative, pharmacological, and
epidural blood patch (EBP). Conservative management has traditionally
involved bed rest and fluids, though there is little evidence to support
either of these measures.
Numerous other reports exist in the literature with promising results
for a variety of other pharmacological agents, including 5HT agonists
(e.g., Sumatriptan), gabapentin, DDAVP, theophylline, and
hydrocortisone. To date, there is insufficient evidence to support their
use. A recent Cochrane review has concluded that therapeutic EBP is
beneficial compared with conservative treatment for
PDPH.6 Even though it is considered the gold
standard of treatment, but the success rate is 50%, and the need for a
second EBP may be 40%.7 Early complications
include backache during injection, fever, bradycardia, and seizures.
Late complications include meningitis, subdural hematoma, arachnoiditis,
and radicular pain.8 In this case, we have
tried pharmacological means such as Neostigmine (20 mcg/kg) and atropine
(10 mcg/kg) after conservative management
failed.9 The numeric Rating Scale was 1/10
after 30 minutes of injection. She did not require any pain medications
after a single dose of neostigmine and atropine. A single dose of
neostigmine and atropine was enough, although this can be given every 8
hours if the headache has not subsided.
Systemic neostigmine does not cross the blood-brain barrier. However, it
can enter the CSF because the BBB and Blood –CSF barriers are
anatomically distinct. Neostigmine increases the level of acetylcholine
in CSF and in the brain through inhibition of cholinesterase, resulting
in cerebral vasoconstriction. The central effects of both drugs
influence both cerebrospinal fluid secretion and cerebral vascular tone,
which are the primary pathophysiological changes in PDPH
(figure.1).10, 13
As described by Ahmed et al in a randomized controlled trial of
involving 85 patients, use of neostigmine/atropine for PDPD treatment
when compared with conservative treatment of hydration and analgesic had
significantly better outcome. However side effects such as abdominal
cramps, muscle twitches and urinary bladder hyperactivity occurred in
the treatment group. Although the study was designed to administer the
interventional drug eight hourly for a duration of 72 hours, the authors
report not needing more than 2 subsequent dosages of the treatment drug
for symptomatic relief. In our case, a single dose was sufficient to
achieve excellent symptomatic relief with no reported side
effects.14