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Other treatments
Although caffeine is often prescribed to prevent or treat PDPH, evidence for its efficacy
is limited and conflicting (Halker et al, 2007). Administration of caffeine combined with
paracetamol for 3 days following spinal anaesthesia did not reduce the incidence of PDPH (or
associated symptoms such as nausea and photohobia) compared with placebo (Esmaoglu et al,
2005 Level II). IV caffeine administered during spinal anaesthesia reduced pain scores, analgesia
requirements and the incidence of moderate‐to‐severe PDPH for up to 5 days (Yucel et al, 1999
Level II). IV theophylline also reduced the severity of PDPH (Ergun et al, 2008 Level II). Oral
caffeine reduced the severity PDPH at 4 hours (Camann et al, 1990 Level II) but did not reduce
the rate of EBP administration (Candido & Stevens, 2003; Halker et al, 2007).
The addition of IV hydrocortisone to conventional therapy (bed rest and analgesia) for
48 hours decreased the intensity of PDPH following spinal anaesthesia for Caesarean section
(Rucklidge et al, 2004 Level II). There was no evidence to support the efficacy of adrenocortico‐
trophic hormone in PDPH (Candido & Stevens, 2003).
There was no evidence to support the efficacy of sumatriptan (Connelly et al, 2000 Level II) in
PDPH, although in open‐label studies other triptans have been reported to have sufficient
benefit to warrant further evaluation (Bussone et al, 2007).
There was no evidence to support the use of epidurally administered saline, dextran or fibrin
glue or neuraxial opioids in the treatment of PDPH (Turnbull & Shepherd, 2003), however
prophylactic epidural morphine in saline significantly reduced the incidence of PDPH and EBP
compared with epidural saline alone following inadvertent dural puncture in parturients
(Al‐metwalli, 2008 Level II).
Other headaches
There is little evidence to guide the treatment of acute cervicogenic headache, post‐traumatic
headache or acute headache attributed to substance use or its withdrawal, although general
principles of evaluation of headache and management of acute pain must apply (Silberstein,
2000). The treatment of giant cell arteritis is with high‐dose steroids, but there are no
evidence‐based guidelines.
Headache attributed to substance withdrawal (severe analgesic ‘rebound’ headache)
CHAPTER 9 Patients may present with severe acute‐on‐chronic headache due to the overuse and/or
withdrawal of antimigrainal (triptans or ergot alkaloids) or analgesics. Inpatient treatment
is often required and may include cessation of analgesics, IV hydration, steroids, nsNSAIDs,
antiemetics and benzodiazepines (Trucco et al, 2005). Evidence for the benefit of steroids is
mixed. One study showed that administration of prednisone led to a significant reduction in
the duration of severe headache compared with placebo (Pageler et al, 2008 Level II). However,
another found that prednisolone did not have a significant effect on ‘rebound headache’
outcomes during the withdrawal phase (Boe et al, 2007 Level II).
A 12‐week open‐label study of a single daily dose of tizanidine in combination with a single
morning dose of NSAID, resolved chronic daily headache in 62% of patients (Smith, 2002
Level III‐3).
Complementary and alternative medicines and therapies
There is no high‐level evidence of efficacy for acupuncture, hypnotherapy, chiropractic, spinal
manipulation or homeopathy in the treatment of migraine (Vernon et al, 1999 Level I; Astin &
Ernst, 2002 Level I; Melchart et al, 2001 Level I). However, acupuncture is an effective non‐
pharmacological intervention in TTH (Linde et al, 2009 Level I).
270 Acute Pain Management: Scientific Evidence
