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Three Part Question

Can [caffeine] be used in [ED patients with post lumbar puncture headache] as part of [effective control of symptoms]?

Clinical Scenario

You performed an LP on a middle aged male patient and you were very pleased with the negative result. Forty-eight hours later the same patient returns with disabling headache associated with nausea and vomiting. After your clinical assessment it all fits into a post lumbar puncture headache (PLPH). You decide upon conservative management as a blood patch requires real expertise. You think you saw an anaesthetist using caffeine for a similar case and you wonder whether you should use it.

Search Strategy

Medline 1950–April week 1 2010, using the interface MESZ Ovid MEDLINE.
[(Caffeine*.ti, ab or exp Caffeine) AND (post-dural puncture headache/dt or exp Post-dural puncture headache or lumbar puncture.ti, ab or exp Spinal puncture)].

The reference sections of review articles were also searched.

Search Outcome

Three hundred and seventy-five papers were found. Two papers were selected as they address the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Sechzer PH. 1978	41 patients with post spinal anaesthesia headaches. After initial injection of either caffeine sodium benzoate (0.5 gm/2 ml) or saline solution (2 ml) patients were asked at between 1 and 2 h “Do you want another injection? If the patient “demanded additional medication” they were administered (CSB 0.5 gm/2 ml).	Double blind randomised controlled trial	Patients were asked whether their headache was relieved	A significant statistical difference (p<0.0001) was found with caffeine sodium benzoate compared to inactive control. In total a 71% response rate in caffeine treated patients.	Randomisation and blinding methods were not described.Poor description of method overall.
Camann WR. 1990	40 post partum patients with post dural puncture headaches. Patients received oral caffeine (300 mg) or a placebo.	Randomised Double-blind, placebo-controlled trial.	Headache was assessed using a visual analogue pain scale.	Relief of post dural puncture headache measured as a change in visual analogue scale from initial to 4 h was significantly better in the caffeine group (36±6) than in the placebo (11±7) p=0.014.	Limited to patients in the immediate post partum period. Small number of patients.No details about randomisation process.

Comment(s)

The patients studied in the trials above are either post partum or spinal anaesthesia populations. The results cannot be extrapolated to patients undergoing diagnostic lumbar puncture. The trials also have small sample size and are methodologically questionable.

Clinical Bottom Line

The evidence for caffeine to effectively treat post dural puncture headache in the emergency room is insufficient.

References

1. Sechzer PH. Post spinal anesthesia headache treated with caffeine. Evaluation with demand method. Curr Ther Rese 1978;24:307–12.
2. Camann WR. Effects of oral caffeine on postdural puncture headache. Anesthesia Analgesia 1990;70:181–4.