Posture and fluids for preventing post-dural puncture headache.
BACKGROUND
Potentially disabling postural headache occurs after dural puncture in 1-70% of patients. It has been suggested that such headaches may be less common if patients routinely have a period of bed rest or receive supplementary fluids after the procedure.


OBJECTIVE
To assess the effects on post dural puncture headache of a period of bed rest versus early mobilisation, of different positions during a period of bed rest, and of administering supplementary fluids after the procedure.


METHODS
We searched the Cochrane Controlled Trials Register (Cochrane Library, Issue 4, 2000), MEDLINE (January 1994-December 1998), and EMBASE (January 1980-December 1998). We also searched the reference lists of articles identified electronically, and contacted trial authors for information about other potentially relevant studies. Date of the most recent search: December 2000.


METHODS
We sought randomised, unconfounded trials, among all types of patients, that compared the effects on post-dural puncture headache of: bed rest versus early mobilisation; head-down tilt versus horizontal or prone versus supine positions during bed rest; or the administration of supplementary fluids versus control.


METHODS
One reviewer extracted data from the reports of all trials considered eligible for inclusion. The authors of included studies were invited to check the information extracted and provide any details that were unavailable in the published reports. Intention-to-treat analyses were performed.


RESULTS
Eleven trials among 1723 patients compared either bed rest with immediate mobilisation or a longer versus a shorter period of bed rest. There was a non-significant relative increase in the odds of the primary outcome of postural headache among patients allocated more rather than less bed rest (196/639 [31%] bed rest versus 169/615 [27%] early mobilisation; odds ratio [OR] 1.21; 95% confidence interval [CI] 0.94 to 1.55). Analyses confined to the methodologically most rigorous trials gave similar results. Only two trials among 126 patients compared different positions during bed rest. No statistically significant differences were found, but small numbers made the comparisons imprecise. One trial among 100 patients assessed fluid supplementation. Again, the numbers of patients and outcome events were small, and indicated the possibility of both reduced and increased postural headache with additional fluids.


CONCLUSIONS
There is no good evidence from randomised trials to suggest that routine bed rest after dural puncture is beneficial. The role of fluid supplementation in the prevention of post-dural puncture headache remains uncertain.
Sudlow
C
C
Department of Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh, UK, EH4 2XU. csudlow@skull.dcn.ed.ac.uk
Warlow
C
C
D001510:Bed Rest; D004434:Early Ambulation; D005440:Fluid Therapy; D006261:Headache / Q000517:prevention & control*; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D013997:Time Factors