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Do Parturients Experience Long-Term Headaches after Epidural-related PDPH?
Abstract Number: 23
Abstract Type: Original Research
Introduction: Few studies have examined persistence of headache symptoms in parturients following diagnosis of postdural puncture headache (PDPH). This prospective longitudinal study examinee continued headache symptoms in women diagnosed with PDPH in the context of a large multicenter randomized controlled trial.
Methods: Following REB approval, labouring women were randomized to receive a 19g vs 17/18g Tuohy type needle for epidural placement. Women with recognized or suspected dural punctures were recorded. All women (regardless of dural puncture status) were followed for the first 14 days post epidural and diagnosed with PDPH using a standardized definition by a blinded external adjudicating body of experts (1 headache specialist/neurologist matched with 1 of 3 senior obstetric anesthesiologists). Assessors and treating staff at study sites were blinded to needle and adjudicator diagnoses of PDPH and diagnosed and managed patients at their discretion. Trained study staff collected data related to headache symptoms on days 1, 3 and 14 using standardized data collection forms. Women with any suggestion of a postural headache were referred for adjudication and followed for a minimum of 6 wks. Information from women with adjudicated positive PDPH and persistent headaches at 12 wks was reviewed by a neurologist to ascertain a diagnosis of chronic headache (standardized definition). Women with persisting headache symptoms were followed up to symptom resolution or 1 yr. Women diagnosed with chronic headache at 3 months post epidural were matched with 4 controls (i.e. women without an adjudicated diagnosis of PDPH in the study) to permit calculation of the odds of chronic headache following PDPH.
Results: A total of 1080 women were randomized; 25 were diagnosed with PDPH by adjudicators using a standardized study definition. Four of 25 women developed postural headaches within the first 24 hours of epidural placement. Six of 25 women developed postural headache symptoms at > 5 days after epidural placement. Six of 25 women developed only a postural neckache (no postural headache). A total of five of 25 women had at least one epidural blood patch. Five out of 25 women with adjudicated PDPH, using the formal study definition, reported continued headache symptoms at 6 weeks. Two women had headaches that persisted at least 6 months. One woman with a documented dural puncture and no prior history of headache met diagnostic criteria for chronic headache at 3 months. This patient reported continued symptoms at one year post epidural. None of the 4 controls (women in the study without PDPH) matched to this patient had chronic headache symptoms at 3 months.
Discussion: This study provides additional insight into modifications required for PDPH diagnosis, the natural history of headache symptoms following diagnosis of PDPH following epidural analgesia in parturients and has significant implications for treatment, research and informed consent.