Cognitive functions during migraine attacks

Tese de doutoramento, Medicina (Neurologia), Universidade de Lisboa, Faculdade de Medicina, 2015Background: Attack-related cognitive symptoms in migraine are frequent yet scarcely characterized and undervalued as contributors of disability. Conflicting evidence arose about an increased risk of cognitive decline in older migraine patients. Objectives: (1) to study the occurrence of cognitive symptoms in migraine attacks; (2) to evaluate objective evidence of cognitive dysfunction in migraine attacks and its neuronal correlates and (3) to study the effect of persisting migraine in cognitive function or cognitive decline in older adults. Methods: Occurrence of attack-related cognitive symptoms was detailed by systematic literature review and a cross-sectional clinical-based systematic survey; their relevance to disability was studied prospectively using headache diaries. An instrument (Mig-SCog) was developed, validated and tested to identify and quantify attack-related subjective cognitive symptoms. Cognitive function during attacks was evaluated by a systematic literature review and a clinical-based prospective two-period randomized cross-over study using an extensive neuropsychological battery. A briefer battery was tested in repeated applications in interictal patients and controls. Brain perfusion during attacks was studied with arterial spin labeling magnetic resonance imaging (ASL-MRI) and cortical response to a working memory task with blood-oxygen level dependent functional magnetic resonance imaging (BOLD-fMRI). A prospective controlled cross-sectional population-based study of neuropsychological performance of older adults with persisting migraine and non-migraine headache was followed by a 5 years re-evaluation of the same sample, to screen for cognitive decline. Results: Cognitive symptoms were the most frequent non-migraine defining symptoms reported in the prodromic(37%) and headache(38%) phases of migraine attacks in a systematic review of 28 series, with a total sample of 8392 patients. Cognitive symptoms are also present in the postdromic or resolution phase, although fatigue (71%) is reported more often. Of 165 patients prospectively surveyed, 87% reported an average of 2.5 attack-related symptoms, over two-thirds executive (attention, processing efficiency and speed). Cognitive symptoms were ranked prospectively by 34 migraine patients recording 229 attacks, being second only to pain in terms of intensity and attack-related disability. An instrument to quantify migraine attack-related symptoms was constructed from a set of 43 candidate items, using factor analysis. The reduced 9 item Mig-SCog is fast to apply covering executive functions and language, having good internal consistency (Cronbachs’ alpha 0.82) and reliability (Cohen’s kappa 0.55) and high correlation with external validity measures such as the 43-candidate item list (rho=0.69) and the Cognitive Failures Questionnaires(rho=0.61). The Mig-SCog presents negligible recall bias (no difference in scores obtained during an attack or while headache free) and Migraine patients score it higher for migraine higher for migraine (7.9±4.6) than for non-headache pain (2.3±2.9, p<0.0006) or pain free (1.6±2.4, p<0.0006). Comparing Mig-SCog scores in migraine and tension-type headache patients, those were higher for migraine in all scale items (p<0.0001) except those related to naming (8 and 9). The AUC of Mig-SCog score for the diagnosis of Migraine was 0.835 (95% CI of 0.763-0.906, p< 0.0001) reinforcing specificity for migraine. Ten studies of neuropsychological evaluation during migraine attacks are available in the literature, only half had data allowing comparison of cognitive performance within and outside attacks (encompassing 163 migraine patients). All these were able to demonstrate some type of impairment (most often executive) although some bias could not be excluded from their study design. In our sample of 24 patients which completed an extensive neuropsychological evaluation in these two conditions (attack and headache-free) controlling for the majority of relevant bias (in particular the practice effect), performance was worse during the attack in the majority of cognitive tests, in particular in word reading speed (p=0.013), verbal learning (p=0.01), short term verbal recall with (p=0.01) and without (p=0.013) semantic cueing and delayed recall with (p=0.003) and without (p=0.05) semantic cues. Another sample of 24 interictal migraine patients and 24 matched controls performed equally in a shorter battery focused on executive functions that was applied twice with a short interval (average 45 days) to test the practice effect of repeated evaluations that was demonstrated in all tests, being significant in Stroop Interference test (p=0.002, multiplicity corrected); a meaningful score change was determined for each raw test scores. We were unable to find any relevant brain perfusion nor brain activation differences evoked by a working memory task during a spontaneous migraine without aura attack of an average intensity of 6.8 on a 0-10 VAS scale and an average duration of 16 hours in a sample of 13 women, compared to being headache-free. Persistent migraine or headache after the age of 50 related to worse performance in some neuropsychological tests (attention and processing speed in migraine patients, n=61; sematic memory and memory retrieval in non-migraine headache, n=50) in a population sample of 478 individuals tested extensively. After 5 years, 275 (57.5%) of the same sample were screened for cognitive decline, that occurred in 14.9% of the sample. Neither migraine nor non-migraine headache influenced the odds of decline. Discussion: Attack-related cognitive symptoms are very frequent, mostly executive and contribute to disability, supporting that they should be addressed as endpoint in clinical trials of acute migraine treatments and included in disability assessments. An efficient way to assess attack-related subjective cognitive symptoms in clinical practice or research is now available – the Mig-SCog. Although migraine-related reversible cognitive dysfunction was demonstrated during attacks, no advances on potential brain mechanisms underlying these findings were made. Interest is focused to obtain more functional data, with studies of evoked activation paradigms, functional connectivity and combined imaging and neurophysiological studies. Although persisting headache in older adults seems to influence executive performance, these changes are most likely adaptive and do not seem to influence the process of brain degeneration and associated cognitive decline

The 2023 Latin America report of the Lancet Countdown on health and climate change: the imperative for health-centred climate-resilient development

In 2023, a series of climatological and political events unfolded, partly driving forward the global climate and health agenda while simultaneously exposing important disparities and vulnerabilities to climate-related events. On the policy front, a significant step forward was marked by the inaugural Health Day at COP28, acknowledging the profound impacts of climate change on health. However, the first-ever Global Stocktake showed an important gap between the current progress and the targets outlined in the Paris Agreement, underscoring the urgent need for further and decisive action. From a Latin American perspective, some questions arise: How do we achieve the change that is needed? How to address the vulnerabilities to climate change in a region with longstanding social inequities? How do we promote intersectoral collaboration to face a complex problem such as climate change? The debate is still ongoing, and in many instances, it is just starting. The renamed regional centre Lancet Countdown Latin America (previously named Lancet Countdown South America) expanded its geographical scope adding Mexico and five Central American countries: Costa Rica, El Salvador, Guatemala, Honduras, and Panama, as a response to the need for stronger collaboration in a region with significant social disparities, including research capacities and funding. The centre is an independent and multidisciplinary collaboration that tracks the links between health and climate change in Latin America, following the global Lancet Countdown’s methodologies and five domains. The Lancet Countdown Latin America work hinges on the commitment of 23 regional academic institutions, United Nations agencies, and 34 researchers who generously contribute their time and expertise. Building from the first report, the 2023 report of the Lancet Countdown Latin America, presents 34 indicators that track the relationship between health and climate change up to 2022, aiming at providing evidence to public decisionmaking with the purpose of improving the health and wellbeing of Latin American populations and reducing social inequities through climate actions focusing on health. This report shows that Latin American populations continue to observe a growing exposure to changing climatic conditions. A warming trend has been observed across all countries in Latin America, with severe direct impacts. In 2022, people were exposed to ambient temperatures, on average, 0.38 ◦C higher than in 1986–2005, with Paraguay experiencing the highest anomaly (+1.9 ◦C), followed by Argentina (+1.2 ◦C) and Uruguay (+0.9 ◦C) (indicator 1.1.1). In 2013–2022, infants were exposed to 248% more heatwave days and people over 65 years old were exposed to 271% more heatwave days than in 1986–2005 (indicator 1.1.2). Also, compared to 1991–2000, in 2013–2022, there were 256 and 189 additional annual hours per person, during which ambient heat posed at least moderate and high risk of heat stress during light outdoor physical activity in Latin America, respectively (indicator 1.1.3). Finally, the region had a 140% increase in heat-related mortality from 2000–2009 to 2013–2022 (indicator 1.1.4). Changes in ecosystems have led to an increased risk of wildfires, exposing individuals to very or extremely high fire danger for more extended periods (indicator 1.2.1). Additionally, the transmission potential for dengue by Aedes aegypti mosquitoes has risen by 54% from 1951–1960 to 2013–2022 (indicator 1.3), which aligns with the recent outbreaks and increasing dengue cases observed across Latin America in recent months. Based on the 2023 report of the Lancet Countdown Latin America, there are three key messages that Latin America needs to further explore and advance for a health-centred climate-resilient development. Latin American countries require intersectoral public policies that simultaneously increase climate resilience, reduce social inequities, improve population health, and reduce greenhouse gas (GHG) emissions. The findings show that adaptation policies in Latin America remain weak, with a pressing need for robust vulnerability and adaptation (V&A) assessments to address climate risks effectively. Unfortunately, such assessments are scarce. Up to 2021, Brazil is the only country that has completed and officially reported a V&A to the 2021 Global Survey conducted by the World Health Organization (WHO). Argentina, Guatemala, and Panama have also conducted them, but they have not been reported (indicator 2.1.1). Similarly, efforts in developing and implementing Health National Adaptation Plans (HNAPs) are varied and limited in scope. Brazil, Chile, and Uruguay are the only countries that have an HNAP (indicator 2.1.2). Moreover, self-reported city-level climate change risk assessments are very limited in the region (indicator 2.1.3). The collaboration between meteorological and health sectors remains insufficient, with only Argentina, Brazil, Colombia, and Guatemala self-reporting some level of integration (indicator 2.2.1), hindering comprehensive responses to climate-related health risks in the region. Additionally, despite the urgent need for action, there has been minimal progress in increasing urban greenspaces across the region since 2015, with only Colombia, Nicaragua, and Venezuela showing slight improvements (indicator 2.2.2). Compounding these challenges is the decrease in funding for climate change adaptation projects in Latin America, as evidenced by the 16% drop in funds allocated by the Green Climate Fund (GCF) in 2022 compared to 2021. Alarmingly, none of the funds approved in 2022 were directed toward climate change and health projects, highlighting a critical gap in addressing health-related climate risks (indicator 2.2.3). From a vulnerability perspective, the Mosquito Risk Index (MoRI) indicates an overall decrease in severe mosquitoborne disease risk in the region due to improvements in water, sanitation, and hygiene (WASH) (indicator 2.3.1). Brazil and Paraguay were the only countries that showed an increase in this indicator. It is worth noting that significant temporal variation within and between countries still persists, suggesting inadequate preparedness for climate-related changes. Overall, population health is not solely determined by the health sector, nor are climate policies a sole responsibility of the environmental sector. More and stronger intersectoral collaboration is needed to pave development pathways that consider solid adaptation to climate change, greater reductions of GHG emissions, and that increase social equity and population health. These policies involve sectors such as finance, transport, energy, housing, health, and agriculture, requiring institutional structures and policy instruments that allow long-term intersectoral collaboration. Latin American countries need to accelerate an energy transition that prioritises people’s health and wellbeing, reduces energy poverty and air pollution, and maximises health and economic gains. In Latin America, there is a notable disparity in energy transition, with electricity generation from coal increasing by an average of 2.6% from 1991–2000 to 2011–2020, posing a challenge to efforts aimed at phasing out coal (indicator 3.1.1). However, this percentage increase is conservative as it may not include all the fossil fuels for thermoelectric electricity generation, especially during climate-related events and when hydropower is affected (Panel 4). Yet, renewable energy sources have been growing, increasing by an average of 5.7% during the same period. Access to clean fuels for cooking remains a concern, with 46.3% of the rural population in Central America and 23.3% in South America lacking access to clean fuels in 2022 (indicator 3.1.2). It is crucial to highlight the concerning overreliance on fossil fuels, particularly liquefied petroleum gas (LPG), as a primary cooking fuel. A significant majority of Latin American populations, approximately 74.6%, rely on LPG for cooking. Transitioning to cleaner heating and cooking alternatives could also have a health benefit by reducing household air pollution-related mortality. Fossil fuels continue to dominate road transport energy in Latin America, accounting for 96%, although some South American countries are increasing the use of biofuels (indicator 3.1.3). Premature mortality attributable to fossil-fuel-derived PM2.5 has shown varied trends across countries, increasing by 3.9% from 2005 to 2020 across Latin America, which corresponds to 123.5 premature deaths per million people (indicator 3.2.1). The Latin American countries with the highest premature mortality rate attributable to PM2.5 in 2020 were Chile, Peru, Brazil, Colombia, Mexico, and Paraguay. Of the total premature deaths attributable to PM2.5 in 2020, 19.1% was from transport, 12.3% from households, 11.6% from industry, and 11% from agriculture. From emission and capture of GHG perspective, commodity-driven deforestation and expansion of agricultural land remain major contributors to tree cover loss in the region, accounting for around 80% of the total loss (indicator 3.3). Additionally, animal-based food production in Latin America contributes 85% to agricultural CO2 equivalent emissions, with Argentina, Brazil, Panama, Paraguay, and Uruguay ranking highest in per capita emissions (indicator 3.4.1). From a health perspective, in 2020, approximately 870,000 deaths were associated with imbalanced diets, of which 155,000 (18%) were linked to high intake of red and processed meat and dairy products (indicator 3.4.2). Energy transition in Latin America is still in its infancy, and as a result, millions of people are currently exposed to dangerous levels of air pollution and energy poverty (i.e., lack of access to essential energy sources or services). As shown in this report, the levels of air pollution, outdoors and indoors, are a significant problem in the whole region, with marked disparities between urban and rural areas. In 2022, Peru, Chile, Mexico, Guatemala, Colombia, El Salvador, Brazil, Uruguay, Honduras, Panama, and Nicaragua were in the top 100 most polluted countries globally. Transitioning to cleaner sources of energy, phasing out fossil fuels, and promoting better energy efficiency in the industrial and housing sectors are not only climate mitigation measures but also huge health and economic opportunities for more prosperous and healthy societies. Latin American countries need to increase climate finance through permanent fiscal commitments and multilateral development banks to pave climate-resilient development pathways. Climate change poses significant economic costs, with investments in mitigation and adaptation measures progressing slowly. In 2022, economic losses due to weather-related extreme events in Latin America were US$15.6 billion –an amount mainly driven by floods and landslides in Brazil–representing 0.28 America’s Gross Domestic Product (GDP) (indicator 4.1.1). In contrast to high-income countries, most of these losses lack insurance coverage, imposing a substantial financial strain on affected families and governments. Heat-related mortality among individuals aged 65 and older in Latin America reached alarming levels, with losses exceeding the equivalent of the average income of 451,000 people annually (indicator 4.1.2). Moreover, the total potential income loss due to heat-related labour capacity reduction amounted to 1.34 disproportionately affecting the agriculture and construction sectors (indicator 4.1.3). Additionally, the economic toll of premature mortality from air pollution was substantial, equivalent to a significant portion of regional GDP (0.61 On a positive note, clean energy investments in the region increased in 2022, surpassing fossil fuel investments. However, in 2020, all countries reviewed continued to offer net-negative carbon prices, revealing fossil fuel subsidies totalling US$23 billion. Venezuela had the highest net subsidies relative to current health expenditure (123%), followed by Argentina (10.5%), Bolivia (10.3%), Ecuador (8.3%), and Chile (5.6%) (indicator 4.2.1). Fossil fuel-based energy is today more expensive than renewable energy. Fossil fuel burning drives climate change and damages the environment on which people depend, and air pollution derived from the burning of fossil fuels causes seven million premature deaths each year worldwide, along with a substantial burden of disease. Transitioning to sustainable, zero-emission energy sources, fostering healthier food systems, and expediting adaptation efforts promise not only environmental benefits but also significant economic gains. However, to implement mitigation and adaptation policies that also improve social wellbeing and prosperity, stronger and solid financial systems are needed. Climate finance in Latin American countries is scarce and strongly depends on political cycles, which threatens adequate responses to the current and future challenges. Progress on the climate agenda is lagging behind the urgent pace required. While engagement with the intersection of health and climate change is increasing, government involvement remains inadequate. Newspaper coverage of health and climate change has been on the rise, peaking in 2022, yet the proportion of climate change articles discussing health has declined over time (indicator 5.1). Although there has been significant growth in the number of scientific papers focusing on Latin America, it still represents less than 4% of global publications on the subject (indicator 5.3). And, while health was mentioned by most Latin American countries at the UN General Debate in 2022, only a few addressed the intersection of health and climate change, indicating a lack of awareness at the governmental level (indicator 5.4). The 2023 Lancet Countdown Latin America report underscores the cascading and compounding health impacts of anthropogenic climate change, marked by increased exposure to heatwaves, wildfires, and vector-borne diseases. Specifically, for Latin America, the report emphasises three critical messages: the urgent action to implement intersectoral public policies that enhance climate resilience across the region; the pressing need to prioritise an energy transition that focuses on health co-benefits and wellbeing, and lastly, that need for increasing climate finance by committing to sustained fiscal efforts and engaging with multilateral development banks. By understanding the problems, addressing the gaps, and taking decisive action, Latin America can navigate the challenges of climate change, fostering a more sustainable and resilient future for its population. Spanish and Portuguese translated versions of this Summary can be found in Appendix B and C, respectively. The full translated report in Spanish is available in Appendix D

Trigeminal activation and ocular autonomic dysfunction after stimulation of the posterior hypothalamus : contribution to the understanding of cluster headache

Tese de mestrado em Neuroftalmologia, apresentada à Faculdade de Medicina da Universidade de Lisboa, 2008The posterior hypothalamus is responsible for the defensive-aggressive response, it is implicated in the sleep/ arousal cycling and it also receives convergent multimodal sensorial input, participating in the brains' pain network. The posterior hypothalamic area may act as the trigger of Cluster Headache attacks, as it is found to be activated in brain image studies specifically in this trigemino-autonomic cephalalgias but not in other primary headaches, such as migraine. Deep brain stimulation of the posterior hypothalamic area is an effective experimental treatment in intractable Cluster Headache patients. Cluster Headache attacks are characterized by a striking clockwise regularity, excruciating unilateral trigeminal pain and concomitant ipsilateral cranial autonomic symptoms. We aimed to develop an animal model to document the effect of PH electric stimulation on the systemic and cranial autonomic system and on the peripheral cranial pain system (the trigeminal ganglion) and to evaluate the effect of nitroglycerin in this model. Using stereotaxic co-ordinates we accessed the PH area and the gasserian ganglion in male adult Wistar rats. The PH was stimulated and activity was obtained in the gasserian ganglion at baseline and after glyceryl trinitrate. Pupil size and tearing were monitored. Firing frequency and post-trigger histograms were analysed and paired-samples T test was used to compare means before and after interventions. Mean differences in firing rates of ganglion cells between experimental conditions were significant when comparing PH stimulation with baseline (t 2.353, p 0.040), PH stimulation after nitroglycerin administration with baseline (t 2.517, p 0.030) and PH stimulation after nitroglycerin with isolated PH stimulation (t 3.017, p 0.013). Stimulation of the PH produced a long latency response of 50 to 150ms. No changes were documented in pupil size and tearing.We found an evident and consistent effect of increased trigeminal ganglion neuronal firing after electric stimulation of the PH of the rat that was potentiated by nitroglycerine without activation of the trigeminal-parasympathetic system.Although with limitations, our results demonstrate a polysynaptic circuitry connecting the PH to the trigeminal peripheral system that is facilitated by nitroglycerin, supporting the hypothesis that the PH has a role in modulating cranial pain. CH attacks are cannot be simply explained by its activation

Matrix Metalloproteinase-9 levels are associated with brain lesion and persistent venous occlusion in patients with cerebral venous thrombosis

© 2021 Thieme. All rights reserved.Background: Elucidating mechanisms of brain damage in cerebral venous thrombosis (CVT) would be instrumental to develop targeted therapies and improve prognosis prediction. Matrix metalloproteinase-9 (MMP-9), a gelatinase that degrades major components of the basal lamina, has been associated to blood-brain barrier disruption. We aimed to assess, in patients with CVT, the temporal change in serum concentrations of MMP-9 and its association with key imaging and clinical outcomes. Methods: Pathophysiology of Venous Infarction-PRediction of InfarctiOn and RecanalIzaTion in CVT (PRIORITy-CVT) was a multicenter prospective cohort study of patients with newly diagnosed CVT. Serial collection of peripheral blood samples performed on day 1, 3, and 8, and standardized magnetic resonance imaging on day 1, 8, and 90. MMP-9 was quantified using enzyme-linked immunosorbent assay in 59 patients and 22 healthy controls. Primary outcomes were parenchymal brain lesion, early evolution of brain lesion, early recanalization, and functional outcome on day 90. Results: CVT patients with parenchymal brain lesion had higher baseline concentrations of MMP-9 compared with controls (adjusted p = 0.001). The area under receiver operating characteristic curve value for MMP-9 for predicting brain lesion was 0.71 (95% confidence interval [CI]: 0.57-0.85, p = 0.009). Patients with venous recanalization showed early decline of circulating MMP-9 and significantly lower levels on day 8 (p = 0.021). Higher MMP-9 on day 8 was associated with persistent venous occlusion (odds ratio: 1.20 [per 20 ng/mL], 95% CI: 1.02-1.43, p = 0.030). Conclusion: We report a novel relationship among MMP-9, parenchymal brain damage, and early venous recanalization, suggesting that circulating MMP-9 is a dynamic marker of brain tissue damage in patients with CVT.This study was supported by 11° Bolsa de Investigação Fundação AstraZeneca - Faculdade de Medicina Universidade de Lisboa, D. Manuel de Mello grant, and Fundação Amélia de Mello. D.A.S. was supported by a doctoral grant SFRH/SINTD/92677/2013 from Fundação para Ciência e Tecnologia.info:eu-repo/semantics/publishedVersio

Blood biomarkers associated with inflammation predict poor prognosis in cerebral venous thrombosis : a multicenter prospective observational study

Copyright © 2020 European Academy of NeurologyBackground and purpose: Experimental studies suggest inflammation can contribute to blood barrier disruption and brain injury in cerebral venous thrombosis (CVT). We aimed to determine whether blood biomarkers of inflammation were associated with the evolution of brain lesions, persistent venous occlusion or functional outcome in patients with CVT. Methods: Pathophysiology of Venous Infarction-Prediction of Infarction and Recanalization in CVT (PRIORITy-CVT) was a multicenter prospective cohort study of patients with newly diagnosed CVT. Evaluation of neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) concentrations in peripheral blood samples was performed at admission in 62 patients. Additional quantification of interleukin (IL)-6 was performed at day 1, 3 and 8 in 35 patients and 22 healthy controls. Standardized magnetic resonance imaging was performed at day 1, 8 and 90. Primary outcomes were early evolution of brain lesion, early recanalization and functional outcome at 90 days. Results: Interleukin-6 levels were increased in patients with CVT with a peak at baseline. IL-6, NLR and CRP levels were not related with brain lesion outcomes or early recanalization but had a significant association with unfavourable functional outcome at 90 days (IL-6: OR = 1.28, 95% CI: 1.05-1.56, P = 0.046; NLR: OR = 1.39, 95% CI: 1.4-1.87, P = 0.014; CRP: OR = 1.756, 95% CI: 1.010-3.051, P = 0.029). Baseline IL-6 had the best discriminative capacity, with an area under the receiver operating characteristic curve to predict unfavourable functional outcome of 0.74 (P = 0.031). Conclusions: Increased baseline levels of NLR, CRP and IL-6 may serve as new predictive markers of worse functional prognosis at 90 days in patients with CVT. No association was found between inflammatory markers and early evolution of brain lesion or venous recanalization.This work was supported by 11° Bolsa de Investigação Fundação AstraZeneca, Faculdade de Medicina Universidade de Lisboa, D. Manuel de Mello grant, Fundação Amélia de Mello. D.A.d.S. was supported by a doctoral grant SFRH/SINTD/92677/2013 from Fundação para a Ciência e a Tecnologia.info:eu-repo/semantics/publishedVersio

Characterisation of microbial attack on archaeological bone

As part of an EU funded project to investigate the factors influencing bone preservation in the archaeological record, more than 250 bones from 41 archaeological sites in five countries spanning four climatic regions were studied for diagenetic alteration. Sites were selected to cover a range of environmental conditions and archaeological contexts. Microscopic and physical (mercury intrusion porosimetry) analyses of these bones revealed that the majority (68%) had suffered microbial attack. Furthermore, significant differences were found between animal and human bone in both the state of preservation and the type of microbial attack present. These differences in preservation might result from differences in early taphonomy of the bones. © 2003 Elsevier Science Ltd. All rights reserved

Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study

© 2020 British Journal of AnaesthesiaBackground: Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP. Methods: Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months. Results: A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19–1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group. Conclusions: Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP

Management practices for postdural puncture headache in obstetrics : a prospective, international, cohort study

Background: Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP. Methods: Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months. Results: A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19-1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score <= 3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group. Conclusions: Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP