Opioids for the Prevention of Post-dural Puncture Headache in Obstetrics: A Systematic Review and Meta-analysis of Efficacy and Safety

Pain Physician. 2021 Nov;24(7):E1155-E1162.


Background: Post-dural puncture headache (PDPH), or spinal headache, is the most common serious complication resulting from iatrogenic puncture of the dura during epidural or spinal anesthesia and cerebrospinal fluid (CSF) leak in pregnant women.

Objective: To analyze the effectiveness and safety of opioids as a prophylaxis approach in treating obstetric patients who underwent unintentional dural puncture during the initiation of neuraxial anesthesia.

Study design: A systematice review and meta-analysis.

Setting: No restriction regarding study type.

Methods: PubMed, Embase, and the Cochrane library were searched for available papers published up to September 2020.

Results: According to the eligibility criteria, 10 studies were included with post-dural puncture headache (PDPH) incidence as the primary outcome and the number of epidural blood patch (EBP) required as the second outcome. The risk estimates of each study were reported as odds ratios (ORs). The results showed morphine does not decrease the incidence of PDPH (OR = 0.45, 95% CI: 0.15 - 1.34, P = 0.153, I2 = 74.4%, Pheterogeneity = 0.004) and the use of EBP (OR = 0.40, 95% CI: 0.08 - 1.95, P = 0.259, I2=73.7%, Pheterogeneity = 0.004). Fentanyl does not decrease the incidence of PDPH (OR = 0.35, 95% CI: 0.01-13.77, P = 0.576, I2 = 81.0%, Pheterogeneity = 0.022).

Limitations: The small number of included studies, high heterogeneity, and variety in study designs.

Conclusions: Exposure to opioids for any reason after the diagnosis of unintentional dural puncture is not associated with a reduced risk of PDPH and does not decrease the need for therapeutic EBP.

Keywords: headache; heterogeneity; iatrogenic injury; meta-analysis; opioids; patch; post-dural puncture; prophylaxis; Epidural blood.