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 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]] | ||
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**[[SAH]] | **[[SAH]] | ||
**[[Amniotic Fluid Embolus]] | **[[Amniotic Fluid Embolus]] | ||
** Choriocarcinoma | **Choriocarcinoma | ||
** [[Air embolism]] | **[[Air embolism]] | ||
{{Postpartum emergencies DDX}} | {{Postpartum emergencies DDX}} | ||
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===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 | ||
** HTN | **HTN | ||
** Epigastric/RUQ pain | **Epigastric/RUQ pain | ||
** Edema | **Edema | ||
** ↑ DTRs | **↑ DTRs | ||
** Proteinuria | **Proteinuria | ||
* CSF: Normal | *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 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 MRI vascular studies, MRI with diffusion-weighted imaging | ||
===[[Postdural Puncture Headaches]]=== | ===[[Postdural Puncture Headaches]]=== | ||
* Due to ↓ intracranial pressure secondary to CSF leak | *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 secondary to dural tears during labor | **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, hypacusia | **+/- tinnitus, diplopia, hypacusia | ||
===Posterior Reversible Encephalopathy Syndrome (PRES)=== | ===Posterior Reversible Encephalopathy Syndrome (PRES)=== | ||
* Onset over hours | *Onset over hours | ||
* Findings | *Findings | ||
** Early seizures | **Early seizures | ||
** Stupor | **Stupor | ||
** Visual loss/hallucinations | **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 | *CSF: normal, +/- ↑ protein | ||
* Imaging | *Imaging | ||
** CT: findings in ~50% of patients | **CT: findings in ~50% of patients | ||
** MRI: Prominent T2-weighted and FLAIR, often in parieto-occipital lobes | **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 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 ↑ | *CSF: 50% of patients with mild pleocytosis and protein ↑ | ||
* 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% cases postpartum | *75% cases postpartum | ||
* Findings | *Findings | ||
** Progressive, diffuse; rarely thunderclap | **Progressive, diffuse; rarely thunderclap | ||
** Dizziness | **Dizziness | ||
** Nausea | **Nausea | ||
** Papilloedema | **Papilloedema | ||
** Lethargy | **Lethargy | ||
** Seizures in 40% | **Seizures in 40% | ||
* 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 | *CT: Often negative | ||
* MRV (preferred): Intraluminal clot flow voids | *MRV (preferred): Intraluminal clot flow voids | ||
==See Also== | ==See Also== | ||
Revision as of 14:08, 4 July 2016
Background
- 40% of postpartum women have headaches; a majority are in the first week of delivery.
Differential Diagnosis
- Primary
- Tension-type headache (most common cause)
- Migraine headache (2nd most common cause)
- 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
Diagnosis
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
- HTN
- 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
- Begin 1-7 day postpartum
- Nuchal/occipital
- Worsen upon standing/resolve with 10-15 mins of recumbency
- +/- tinnitus, diplopia, hypacusia
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% cases postpartum
- Findings
- Progressive, diffuse; rarely thunderclap
- Dizziness
- Nausea
- Papilloedema
- 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.