Cosyntropin a potential treatment option for paediatric refractory postdural puncture headache

In the treatment of paediatric patients with postdural puncture headache refractory to conservative therapies, the use of cosyntropin results in rapid pain relief, according to data from a retrospective analysis.

Researchers examined the medical records of 26 paediatric patients (median age, 15 years; median weight, 58.1 kg) with refractory postdural puncture headache who had received 37 doses of cosyntropin administered intravenously. They collected information on indication, dosing information, efficacy and side effects. The primary and secondary efficacy measures were response (defined as 50-percent reduction in pain score) and time to discharge after first dose, respectively.

Reasons for dural puncture varied, mostly to aid in diagnosis of neurologic conditions. Onset of headache ranged from immediate to 120 hours after dural puncture, with a median time of 28 hours in 15 patients with reliable documentation of headache onset. All patients had failed at least two prior conservative therapies, including hydration, caffeine, nonsteroidal anti-inflammatory drugs and/or antiemetics (corticosteroids, diphenhydramine, metoclopramide or ondansetron).

Cosyntropin dosing ranged from 5­–15 mcg/kg (median, 10.4 mcg/kg). Pain scores decreased significantly following the first dose of cosyntropin (p=0.008), with 81 percent of patients (n=21) achieving either 50-percent reduction in pain or discharge within 24 hours after the first dose.

Thirteen patients achieved a 50-percent pain reduction prior to discharge at a median of 5 hours following the first dose. Median time to discharge after first dose was 20 hours.

Ten patients were given more than one dose of cosyntropin, while three patients required epidural blood patch (EBP). There were no treatment-related adverse effects documented.

The present data suggest that cosyntropin represents an attractive, potential outpatient treatment alternative for paediatric patients with refractory postdural puncture headache who prefer to avoid EBP, which is invasive. Additional prospective studies are warranted to establish appropriate dosing and measures of efficacy.