• Abdelaal Ahmed MahmoudAhmedAFrom the Faculty of Medicine, Department of Anesthesiology, Beni-Suef University, Beni Suef, Egypt.Department of Anaesthesia, Tallaght University Hospital, Dublin, Ireland., Amr Zaki Mansour, Hany Mahmoud Yassin, Hazem Abdelwahab Hussein, Ahmed Moustafa Kamal, Mohamed Elayashy, Mohamed Farid Elemady, Hany W Elkady, Hatem Elmoutaz Mahmoud, Barbara Cusack, Hisham Hosny, and Mohamed Abdelhaq.
• From the Faculty of Medicine, Department of Anesthesiology, Beni-Suef University, Beni Suef, Egypt.
• Anesth. Analg. 2018 Dec 1; 127 (6): 1434-1439.

BackgroundPostdural puncture headache (PDPH) lacks a standard evidence-based treatment. A patient treated with neostigmine for severe PDPH prompted this study.MethodsThis randomized, controlled, double-blind study compared neostigmine and atropine (n = 41) versus a saline placebo (n = 44) for treating PDPH in addition to conservative management of 85 patients with hydration and analgesics. The primary outcome was a visual analog scale score of ≤3 at 6, 12, 24, 36, 48, and 72 hours after intervention. Secondary outcomes were the need for an epidural blood patch, neck stiffness, nausea, and vomiting. Patients received either neostigmine 20 μg/kg and atropine 10 μg/kg or an equal volume of saline.ResultsVisual analog scale scores were significantly better (P< .001) with neostigmine/atropine than with saline treatment at all time intervals after intervention. No patients in the neostigmine/atropine group needed epidural blood patch compared with 7 (15.9%) in the placebo group (P< .001). Patients required no >2 doses of neostigmine/atropine. There were no between-group differences in neck stiffness, nausea, or vomiting. Complications including abdominal cramps, muscle twitches, and urinary bladder hyperactivity occurred only in the neostigmine/atropine group (P< .001).ConclusionsNeostigmine/atropine was effective in treating PDPH after only 2 doses. Neostigmine can pass the choroid plexus but not the blood-brain barrier. The central effects of both drugs influence both cerebrospinal fluid secretion and cerebral vascular tone, which are the primary pathophysiological changes in PDPH. The results are consistent with previous studies and clinical reports of neostigmine activity.

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