1. 2013;16;E25-E30Cigarette Smokers Have Reduced Risk for Post-Dural Puncture Headache
   Retrospective Review
   Heather S Dodge, BA, Nosakhare N Ekhator, MS, Lena Jefferson-Wilson, MD, Mark Fischer, BA, Ian Jansen, BA, Paul S. Horn, PhD, William E. Hurford, MD, and Thomas D. Geracioti, MD.

BACKGROUND:  Although headache is the most common complication of dural puncture, knowledge gaps remain about patient-related risks. Data are lacking on the role, if any, of tobacco smoking, race, anxiety, depression, and Post Traumatic Stress Disorder (PTSD) in conferring risk for post-dural puncture headache (PDPH).

OBJECTIVE:  To determine the influence of tobacco smoking, race, anxiety,depressed mood, and PTSD on the risk for PDPH.

STUDY DESIGN:  Retrospective chart review, single site.

METHODS:  We determined the incidence of significant PDPH according to age, sex, race, smoking status, and psychiatric diagnosis in 153 consecutive research patients at the Cincinnati Veterans Affairs Medical Center who had continuous cerebrospinal fluid (CSF) sampling performed after using a large-bore (17 gauge) Tuohy needle to place a 20-gauge polyamide catheter in the lumbar spinal canal.

RESULTS:  Thirty-nine subjects (25.5%) had significant PDPH, defined as requiring an epidural blood patch for therapy (an average of 4 days post-procedure).  Greater age was associated with a decreased risk of PDPH (P = 0.008); subjects over the age of 40 had the lowest incidence (15.7%). Women and men had a 31.4% and 23.7% incidence of PDPH, respectively; these were not significantly different (P = 0.38).  Neither were rates of PDPH in Caucasians (28.0%) and African-Americans (15.6%) significantly different (P = 0.18)   Healthy controls had a higher incidence of PDPH than patients with PTSD (P = 0.032).  Smokers had a lower incidence of PDPH than non-smokers, 13.7% vs. 34.1% (P = 0.009). 

LIMITATIONS:  This was not a prospective study, rather a retrospective chart review. 

CONCLUSION:  Most notably, smokers had a considerably reduced rate of PDPH in comparison with non-smokers.  This information could be a useful addition to the clinical assessment of relative risk for PDPH.  Further research into the mechanisms by which tobacco smoking may inhibit PDPH, such as nicotine stimulation of dopamine neurotransmission or alterations in coagulation, appears warranted.