Postpartum headache: Difference between revisions
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==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 | ||
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**[[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 | ||
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*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]]=== | ||
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**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 reversible encephalopathy syndrome]] (PRES)=== | |||
*Onset over hours | *Onset over hours | ||
*Findings | *Findings | ||
**Early seizures | **Early [[seizures]] | ||
**Stupor | **[[AMS|Stupor]] | ||
**Visual loss/hallucinations | **[[vision loss|Visual loss]]/[[hallucinations]] | ||
**Dull/throbbing headache (not thunderclap) | **Dull/throbbing headache (not thunderclap) | ||
*Symptoms resolve within days-weeks if BP controlled | *Symptoms resolve within days-weeks if BP controlled | ||
*CSF: normal, +/- ↑ protein | *[[LP|CSF]]: normal, +/- ↑ protein | ||
*Imaging | *Imaging | ||
**CT: findings in ~50% of patients | **[[head CT|CT]]: findings in ~50% of patients | ||
**MRI: Prominent T2-weighted and FLAIR, often in parieto-occipital lobes | **[[Brain MRI|MRI]]: Prominent T2-weighted and FLAIR, often in parieto-occipital lobes | ||
**Intracerebral hemorrhage in 15% of patients | **[[Intracerebral hemorrhage]] in 15% of patients | ||
===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 deficits | **Transient [[focal neuro deficits|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 | ||
*CSF: 50% of patients with mild pleocytosis and protein ↑ | *[[LP|CSF]]: 50% of patients with mild pleocytosis and protein ↑ | ||
*CT: normal | *[[CT head|CT]]: normal | ||
*CT angio/MRI | *CT angio/MRI | ||
**String-of-beads constriction pattern of cerebral arteries | **String-of-beads constriction pattern of cerebral arteries | ||
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===[[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]] | |||
*CSF | |||
**↑ opening pressure in 80% | **↑ opening pressure in 80% | ||
**↑ protein/cell counts in 35-50% | **↑ protein/cell counts in 35-50% | ||
*CT: Often negative | *[[Head CT|CT]]: Often negative | ||
*MRV (preferred): Intraluminal clot flow voids | *[[brian MRI|MRV]] (preferred): Intraluminal clot flow voids | ||
==See Also== | ==See Also== | ||
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[[Category:Neurology]] | [[Category:Neurology]] | ||
[[Category:OBGYN]] | [[Category:OBGYN]] | ||
[[Category:Symptoms]] | |||
Revision as of 00:17, 2 October 2019
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.