Intravenous Neostigmine-atropine for Refractory Post-dural Puncture Headache in Obstetric Patients: A Case Series

Abstract

Post-dural puncture headache is an important complication of neuraxial anaesthesia and may be particularly disabling in obstetric patients during the early postpartum period. Although many cases respond to conservative measures, persistent symptoms may interfere with ambulation, breastfeeding, and maternal recovery and may require an epidural blood patch. This retrospective case series describes the clinical response to intravenous neostigmine–atropine in six obstetric patients with post-dural puncture headache that persisted despite 48–72 hours of conservative management. Post-dural puncture headache was diagnosed clinically on the basis of orthostatic headache occurring within five days of neuraxial anaesthesia, after exclusion of alternative causes where clinically indicated. All patients received intravenous neostigmine 20 μg/kg with atropine 10 μg/kg, diluted in 20 mL of normal saline and administered over five minutes under haemodynamic monitoring. Pain severity was assessed using a 10-point visual analogue scale. Outcomes included change in headache severity, need for repeat dosing, requirement for epidural blood patch, recurrence before discharge, and adverse effects. The six patients were aged 26–31 years. Four developed headache after spinal anaesthesia with a 25G Quincke needle, and two after accidental dural puncture during labour epidural placement with an 18G Tuohy needle. Baseline visual analogue scale scores were 7–8 after conservative therapy. Following treatment, final scores decreased to 1–2 within 10–16 hours. Five patients required a second dose at 8 hours. No patient required epidural blood patch during the hospital stay, and no clinically significant adverse effects were observed. Intravenous neostigmine–atropine was associated with improvement in headache severity in this small series of obstetric patients with persistent post-dural puncture headache. Larger controlled studies are required to confirm efficacy, safety, optimal dosing, and durability of response.