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