Postpartum headache: Difference between revisions
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==Background== | ==Background== | ||
* 40% of postpartum women have headaches; a majority are in the first week of delivery. | *40% of postpartum women have headaches; a majority are in the first week of delivery. | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
* Primary | *Primary | ||
** Tension-type headache (most common cause) | **Tension-type [[tension headache|headache]] (most common cause) | ||
** Migraine headache (2nd most common cause) | **[[Migraine]] headache (2nd most common cause) | ||
* Secondary | *Secondary | ||
**[[Postdural puncture headache]] | **[[Postdural puncture headache]] | ||
**[[Preeclampsia]]/[[Eclampsia]] | **[[Preeclampsia]]/[[Eclampsia]] | ||
**[[Cerebral venous sinus thrombosis]] | **[[Cerebral venous sinus thrombosis]] | ||
**[[Stroke]] (ischemic or hemorrhagic) | **[[Stroke]] (ischemic or hemorrhagic) | ||
**Ruptured aneurysm or malformation | **Ruptured aneurysm or [[AVM|malformation]] | ||
**[[Posterior Reversible Encephalopathy Syndrome (PRES)]] | **[[Posterior Reversible Encephalopathy Syndrome (PRES)]] | ||
**Postpartum cerebral angiopathy | **Postpartum cerebral angiopathy | ||
| Line 20: | Line 20: | ||
**[[SAH]] | **[[SAH]] | ||
**[[Amniotic Fluid Embolus]] | **[[Amniotic Fluid Embolus]] | ||
** Choriocarcinoma | **Choriocarcinoma | ||
** [[Air embolism]] | **[[Air embolism]] | ||
{{Postpartum emergencies DDX}} | {{Postpartum emergencies DDX}} | ||
== | ==Evaluation== | ||
===Primary Headaches=== | ===Primary Headaches=== | ||
* Tension-type headache most common | *Tension-type headache most common | ||
* Incidence of migraines increases postpartum due to estrogen withdrawal | *Incidence of migraines increases postpartum due to estrogen withdrawal | ||
** Avoid ergotamines in breast-feeding patients | **Avoid ergotamines in breast-feeding patients | ||
===[[Preeclampsia]]=== | ===[[Preeclampsia]]=== | ||
* Findings: | *Findings: | ||
** Bilateral, throbbing headache | **Bilateral, throbbing headache | ||
** Blurred vision/scintillating scotomata | **[[Blurred vision]]/scintillating scotomata | ||
** | **[[Hypertension]] | ||
** Epigastric/RUQ pain | **[[epigastric pain|Epigastric]]/[[RUQ pain]] | ||
** Edema | **Edema | ||
** ↑ DTRs | **↑ DTRs | ||
** Proteinuria | **[[Proteinuria]] | ||
* CSF: Normal | *[[LP|CSF]]: Normal | ||
===[[SAH]]=== | ===[[SAH]]=== | ||
* ↑ risk due to combination of vasodilatation from hyperestrogenic state and vasalvic pressure from labor | *↑ risk due to combination of vasodilatation from hyperestrogenic state and vasalvic pressure from labor | ||
* Require CT → LP if CT negative for SAH | *Require [[head CT|CT]] → [[LP]] if CT negative for SAH | ||
** If above negative, consider CVT vs. RCVS vs. cervicocranial arterial dissection | **If above negative, consider CVT vs. RCVS vs. cervicocranial arterial dissection | ||
** Further work-up includes MRI vascular studies, MRI with diffusion-weighted imaging | **Further work-up includes [[brain MRI|MRI]] vascular studies, MRI with diffusion-weighted imaging | ||
===[[Postdural Puncture Headaches]]=== | ===[[Postdural Puncture Headaches]]=== | ||
* Due to ↓ intracranial pressure | *Due to ↓ intracranial pressure secondary to CSF leak | ||
* Incidence: 0.5-1.5% of women receiving epidural anesthesia | *Incidence: 0.5-1.5% of women receiving epidural anesthesia | ||
** Can occur in women who have not received epidural | **Can occur in women who have not received epidural secondary to dural tears during labor | ||
* Findings | *Findings | ||
** Begin 1-7 day postpartum | **Begin 1-7 day postpartum | ||
** Nuchal/occipital | **Nuchal/occipital | ||
** Worsen upon standing/resolve with 10-15 mins of recumbency | **Worsen upon standing/resolve with 10-15 mins of recumbency | ||
** +/- tinnitus, diplopia, | **+/- [[tinnitus]], [[diplopia]], hypoacusia | ||
===Posterior | ===[[Posterior reversible encephalopathy syndrome]] (PRES)=== | ||
*Onset over hours | |||
* Onset over hours | *Findings | ||
* Findings | **Early [[seizures]] | ||
** Early seizures | **[[AMS|Stupor]] | ||
** Stupor | **[[vision loss|Visual loss]]/[[hallucinations]] | ||
** Visual loss/hallucinations | **Dull/throbbing headache (not thunderclap) | ||
** Dull/throbbing headache (not thunderclap) | *Symptoms resolve within days-weeks if BP controlled | ||
*[[LP|CSF]]: normal, +/- ↑ protein | |||
* Symptoms resolve within days-weeks if BP controlled | *Imaging | ||
* CSF: normal, +/- ↑ protein | **[[head CT|CT]]: findings in ~50% of patients | ||
* Imaging | **[[Brain MRI|MRI]]: Prominent T2-weighted and FLAIR, often in parieto-occipital lobes | ||
** CT: findings in ~50% of | **[[Intracerebral hemorrhage]] in 15% of patients | ||
** MRI: Prominent T2-weighted and FLAIR, often in parieto-occipital lobes | |||
** Intracerebral hemorrhage in 15% of | |||
===Reversible Cerebral Vasoconstriction Syndrome (RCVS)=== | ===Reversible Cerebral Vasoconstriction Syndrome (RCVS)=== | ||
*Abrupt onset | |||
* Abrupt onset | *Findings | ||
* Findings | **"Thunderclap" headache | ||
** "Thunderclap" headache | **Multiple episodes | ||
** Multiple episodes | **+/- [[seizures]] | ||
** +/- seizures | **Transient [[focal neuro deficits|focal deficits]] | ||
** Transient focal deficits | *Typical Course | ||
* Typical Course | **First week: headaches | ||
** First week: headaches | **Second week: [[intracerebral hemorrhage]] | ||
** Second week: intracerebral hemorrhage | **Third week: Ischemic complications | ||
** Third week: Ischemic complications | *[[LP|CSF]]: 50% of patients with mild pleocytosis and protein ↑ | ||
* CSF: 50% of | *[[CT head|CT]]: normal | ||
* CT: normal | *CT angio/MRI | ||
* CT angio/MRI | **String-of-beads constriction pattern of cerebral arteries | ||
** String-of-beads constriction pattern of cerebral arteries | **Digital subtraction angiogram more sensitive | ||
** Digital subtraction angiogram more sensitive | **+/- cervical arterial dissection | ||
** +/- cervical arterial dissection | **Initial arteriogram may be negative | ||
** Initial arteriogram may be negative | |||
===[[Cerebral venous sinus thrombosis]]=== | ===[[Cerebral venous sinus thrombosis]]=== | ||
*75% of cases are postpartum | |||
* 75% cases postpartum | *Findings | ||
* Findings | **Progressive, diffuse; rarely thunderclap | ||
** Progressive, diffuse; rarely thunderclap | **[[Dizziness]] | ||
** Dizziness | **[[Nausea]] | ||
** Nausea | **[[Papilledema]] | ||
** | **[[Lethargy]] | ||
** Lethargy | **[[Seizures]] in 40% | ||
** Seizures in 40% | *[[LP|CSF]] | ||
**↑ opening pressure in 80% | |||
* CSF | **↑ protein/cell counts in 35-50% | ||
** ↑ opening pressure in 80% | *[[Head CT|CT]]: Often negative | ||
** ↑ protein/cell counts in 35-50% | *[[brain MRI|MRV]] (preferred): Intraluminal clot flow voids | ||
* CT: Often negative | |||
* MRV (preferred): Intraluminal clot flow voids | |||
==See Also== | ==See Also== | ||
| Line 118: | Line 113: | ||
==References== | ==References== | ||
# Edlow JA, Caplan LR, O'Brien K, Tibbles CD. Diagnosis of acute neurological emergencies in pregnant and post-partum women. The Lancet Neurology 2013;12:175-85. | #Edlow JA, Caplan LR, O'Brien K, Tibbles CD. Diagnosis of acute neurological emergencies in pregnant and post-partum women. The Lancet Neurology 2013;12:175-85. | ||
# Goldszmidt E, Kern R, Chaput A, Macarthur A. The incidence and etiology of postpartum headaches: a prospective cohort study. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2005;52:971-7. | #Goldszmidt E, Kern R, Chaput A, Macarthur A. The incidence and etiology of postpartum headaches: a prospective cohort study. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2005;52:971-7. | ||
# Klein AM, Loder E. Postpartum headache. International journal of obstetric anesthesia 2010;19:422-30. | #Klein AM, Loder E. Postpartum headache. International journal of obstetric anesthesia 2010;19:422-30. | ||
# Stella CL, Jodicke CD, How HY, Harkness UF, Sibai BM. Postpartum headache: is your work-up complete? American journal of obstetrics and gynecology 2007;196:318 e1-7. | #Stella CL, Jodicke CD, How HY, Harkness UF, Sibai BM. Postpartum headache: is your work-up complete? American journal of obstetrics and gynecology 2007;196:318 e1-7. | ||
[[Category:Neurology]] | [[Category:Neurology]] | ||
[[Category:OBGYN]] | [[Category:OBGYN]] | ||
[[Category:Symptoms]] | |||
Latest revision as of 02:29, 14 December 2020
Background
- 40% of postpartum women have headaches; a majority are in the first week of delivery.
Differential Diagnosis
- Secondary
- Postdural puncture headache
- Preeclampsia/Eclampsia
- Cerebral venous sinus thrombosis
- Stroke (ischemic or hemorrhagic)
- Ruptured aneurysm or malformation
- Posterior Reversible Encephalopathy Syndrome (PRES)
- Postpartum cerebral angiopathy
- Pseudotumor cerebri
- SAH
- Amniotic Fluid Embolus
- Choriocarcinoma
- Air embolism
3rd Trimester/Postpartum Emergencies
- Acute fatty liver of pregnancy
- Amniotic fluid embolus
- Chorioamnionitis
- Eclampsia
- HELLP syndrome
- Mastitis
- Peripartum cardiomyopathy
- Postpartum endometritis (postpartum PID)
- Postpartum headache
- Postpartum hemorrhage
- Preeclampsia
- Resuscitative hysterotomy
- Retained products of conception
- Septic abortion
- Uterine rupture
Evaluation
Primary Headaches
- Tension-type headache most common
- Incidence of migraines increases postpartum due to estrogen withdrawal
- Avoid ergotamines in breast-feeding patients
Preeclampsia
- Findings:
- Bilateral, throbbing headache
- Blurred vision/scintillating scotomata
- Hypertension
- Epigastric/RUQ pain
- Edema
- ↑ DTRs
- Proteinuria
- CSF: Normal
SAH
- ↑ risk due to combination of vasodilatation from hyperestrogenic state and vasalvic pressure from labor
- Require CT → LP if CT negative for SAH
- If above negative, consider CVT vs. RCVS vs. cervicocranial arterial dissection
- Further work-up includes MRI vascular studies, MRI with diffusion-weighted imaging
Postdural Puncture Headaches
- Due to ↓ intracranial pressure secondary to CSF leak
- Incidence: 0.5-1.5% of women receiving epidural anesthesia
- Can occur in women who have not received epidural secondary to dural tears during labor
- Findings
Posterior reversible encephalopathy syndrome (PRES)
- Onset over hours
- Findings
- Early seizures
- Stupor
- Visual loss/hallucinations
- Dull/throbbing headache (not thunderclap)
- Symptoms resolve within days-weeks if BP controlled
- CSF: normal, +/- ↑ protein
- Imaging
- CT: findings in ~50% of patients
- MRI: Prominent T2-weighted and FLAIR, often in parieto-occipital lobes
- Intracerebral hemorrhage in 15% of patients
Reversible Cerebral Vasoconstriction Syndrome (RCVS)
- Abrupt onset
- Findings
- "Thunderclap" headache
- Multiple episodes
- +/- seizures
- Transient focal deficits
- Typical Course
- First week: headaches
- Second week: intracerebral hemorrhage
- Third week: Ischemic complications
- CSF: 50% of patients with mild pleocytosis and protein ↑
- CT: normal
- CT angio/MRI
- String-of-beads constriction pattern of cerebral arteries
- Digital subtraction angiogram more sensitive
- +/- cervical arterial dissection
- Initial arteriogram may be negative
Cerebral venous sinus thrombosis
- 75% of cases are postpartum
- Findings
- Progressive, diffuse; rarely thunderclap
- Dizziness
- Nausea
- Papilledema
- Lethargy
- Seizures in 40%
- CSF
- ↑ opening pressure in 80%
- ↑ protein/cell counts in 35-50%
- CT: Often negative
- MRV (preferred): Intraluminal clot flow voids
See Also
References
- Edlow JA, Caplan LR, O'Brien K, Tibbles CD. Diagnosis of acute neurological emergencies in pregnant and post-partum women. The Lancet Neurology 2013;12:175-85.
- Goldszmidt E, Kern R, Chaput A, Macarthur A. The incidence and etiology of postpartum headaches: a prospective cohort study. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2005;52:971-7.
- Klein AM, Loder E. Postpartum headache. International journal of obstetric anesthesia 2010;19:422-30.
- Stella CL, Jodicke CD, How HY, Harkness UF, Sibai BM. Postpartum headache: is your work-up complete? American journal of obstetrics and gynecology 2007;196:318 e1-7.