Intravenous Cosyntropin in the Management of a Post-Dural Puncture Headache
Ann-Marie Surette, MD1, Robert Herreria, MD2, Laura Morello, MD2 University 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.
- 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
- 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
- bimodal response to cosyntropin
- multiple types of responders: early, late, non-responders
- immediate response with later effect natural course
- largest RCT
- cosyntropin is more effective as prophylaxis for PDPH
Questions: best delivery route, total dose, number of doses, and length of infusion.
- 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.
- 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.
- 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.
- Rucklidge, M; Yentis, S; Paech, M. Synacthen Depot for the treatment of postdural puncture headache. Anaesthesia, 2004; 59: 138-141.
- 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.
- Hakim, SM. Cosyntropin for Prophylaxis against Postdural Puncture Headache after Accidental Dural Puncture. Anesthesiology 2010; 113: 413-420.
- Gaiser, R. Postdural Puncture Headache: An Evidence-Based Approach. Anesthesiology Clin 2017, 35: 157-167.
- Kshatri A; Foster P. Adrenocorticotropic Hormone Infusion as a Novel Treatment for Postdural Puncture Headache. Regional Anesthesia 22(5): 432-434, 1997.