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Intravenous Cosyntropin in the Management of a Post-Dural Puncture Headache

Intravenous Cosyntropin in the Management of a Post-Dural Puncture Headache

Ann-Marie Surette, MD1, Robert Herreria, MD2,  Laura Morello, MDUniversity of Connecticut School of Medicine, Farmington, CT  2St. Francis Hospital and Medical Center, Hartford, CT


Post-dural puncture headache (PDPH) is the most common complication following labor neuraxial anesthesia. While epidural blood patch (EBP) is the most effective treatment, a subset of patients will refuse or have an absolute contraindication.

It is important to provide alternative treatment options for patients with PDPH. One pharmacologic treatment option is cosyntropin, a synthetic adrenocorticotropic hormone (ACTH).



31 yo G1 P0000 at 41 weeks for induction of labor due to late-term pregnancy.


Labor course:

  • dinoprostone
  • oxytocin


Epidural placement:

  • multiple attempts by resident and attending
  • successful placement at L3-L4 with adequate pain relief
    ● no accidental dural puncture
  • multiple boluses with poor pain control


Cesarean section:

  • multiple attempts to perform spinal
  • multiple attempts to place epidural
  • clear fluid obtained from Tuohy needle at L3-L4 → injected 1.8ml of 0.75% hyperbaric bupivacaine
  • no surgical anesthesia obtained
  • general anesthesia required


  • severe 10/10, positional headache (HA)→ occipital with radiation to the neck
  • IV hydration, oral analgesics, and oral Fioricet
  • refused EBP due to prior neuraxial difficulty
  • 750mcg IV cosyntropin in 1L normal saline over 1 hour
  • within 4 hours, visual analogue scale (VAS) score 5/10 with improved functional status


  • increase in HA, VAS scores 6-7/10
  • no change in functional status


  • improvement in HA, VAS scores 5/10
  • discharged home, no subsequent ED visits/treatment



Cosyntropin: analog of the first 24 amino acids of ACTH

  • same hormonal activity, less antigenicity

Mechanism of action:

  • increased aldosterone secretion
  • promotion of dural edema→ overlap of puncture site
  • increased CSF production through active Na+ transport
  • release of brain B-endorphins


Multiple case reports have been published showing a benefit of cosyntropin in PDPH management. RCTs are inconclusive.


Rucklidge 2004: 18 women with PDPH, IM ACTH vs. IM saline.

VAS scores: pre-treatment and at 6, 12, 24, 48 hrs.

  • Results: No difference in VAS scores or rescue EBP

eger 2012: 33 patients with PDPH, IV cosyntropin vs. IV caffeine. VAS scores: pre-treatment and at 60 and 120 minutes.

  • Results: No difference in efficacy rates or VAS scores


Hanling 2016: 28 patients with PDPH, IV cosyntropin vs. EBP.

VAS/function scores: pre-treatment and Days 0, 1, 3, 7.

  • Results: EBP superior on Day 1

Cosyntropin = EBP on Days 0, 3, 7

Hakim 2010:  90 women with accidental dural puncture, IV cosyntropin vs. placebo 30 minutes after vaginal delivery.  Assessed for HA and VAS scores every 8 hours.

  • Results: Significantly fewer patients in the cosyntropin group developed a PDPH or required an EBP


Additional research needs to be done before ACTH can be routinely recommended as a pharmacologic treatment of PDPH. RCTs:

  • small with overall high risk of bias
  • heterogenous data
  • different measured outcomes

Zeger 2012: no difference between cosyntropin and caffeine

  • risk of attrition bias
  • short followup times

Hanling 2016:

  • bimodal response to cosyntropin
  • multiple types of responders: early, late, non-responders
  • immediate response with later effect natural course

Hakim 2010:

  • largest RCT
  • cosyntropin is more effective as prophylaxis for PDPH

Questions: best delivery route, total dose, number of doses, and length of infusion.



  1. Katz, D and Beilin Y. Review of the Alternatives to Epidural Blood Patch for Treatment of Postdural Puncture Headache in the Parturient. Anesth Analg 2017; 124: 1219-28.
  2. Basurto Ona, X; Osorio, D; Bonfill Cosp, X. Drug therapy for treating post-dural puncture headache. The Cochrane Database of systematic reviews, 2015 (7), PP. CD007887.
  3. Hanling, SR; Lagrew, JE; Colmenar, D; Quiko, A; Drastol, C. Intravenous Cosyntropin Versus Epidural Blood Patch for Treatment of Postdural Puncture Headache. Pain Medicine 2016; 17: 1337-1342.
  4. Rucklidge, M; Yentis, S; Paech, M. Synacthen Depot for the treatment of postdural puncture headache. Anaesthesia, 2004; 59: 138-141.
  5. Zeger, W; Younggren, B; Smith, L. Comparison of cosyntropin versus caffeine for post-dural puncture headaches: A randomized dounle-blind trial. World J Emerg Med 2012; 3: 182-185.
  6. Hakim, SM. Cosyntropin for Prophylaxis against Postdural Puncture Headache after Accidental Dural Puncture. Anesthesiology 2010; 113: 413-420.
  7. Gaiser, R. Postdural Puncture Headache: An Evidence-Based Approach. Anesthesiology Clin 2017, 35: 157-167.
  8. Kshatri A; Foster P. Adrenocorticotropic Hormone Infusion as a Novel Treatment for Postdural Puncture Headache. Regional Anesthesia 22(5): 432-434, 1997.

Intravenous Cosyntropin in the Management of a Post-Dural Puncture Headache