View source for Postpartum headache


==Background==

*40% of postpartum women have headaches; a majority are in the first week of delivery.

==Differential Diagnosis==
*Primary
**Tension-type [[tension headache|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 [[AVM|malformation]]
**[[Posterior Reversible Encephalopathy Syndrome (PRES)]]
**Postpartum cerebral angiopathy
**[[Pseudotumor cerebri]]
**[[SAH]]
**[[Amniotic Fluid Embolus]] 
**Choriocarcinoma 
**[[Air embolism]]

{{Postpartum emergencies DDX}}

==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 pain|Epigastric]]/[[RUQ pain]] 
**Edema
**↑ DTRs
**[[Proteinuria]]

*[[LP|CSF]]: Normal

===[[SAH]]===
*↑ risk due to combination of vasodilatation from hyperestrogenic state and vasalvic pressure from labor 
*Require [[head CT|CT]] → [[LP]] if CT negative for SAH
**If above negative, consider CVT vs. RCVS vs. cervicocranial arterial dissection
**Further work-up includes [[brain MRI|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]], hypoacusia

===[[Posterior reversible encephalopathy syndrome]] (PRES)===
*Onset over hours
*Findings
**Early [[seizures]]
**[[AMS|Stupor]]
**[[vision loss|Visual loss]]/[[hallucinations]]
**Dull/throbbing headache (not thunderclap)
*Symptoms resolve within days-weeks if BP controlled
*[[LP|CSF]]: normal, +/- ↑ protein
*Imaging
**[[head CT|CT]]: findings in ~50% of patients
**[[Brain MRI|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 neuro deficits|focal deficits]]
*Typical Course
**First week: headaches
**Second week: [[intracerebral hemorrhage]]
**Third week: Ischemic complications 
*[[LP|CSF]]: 50% of patients with mild pleocytosis and protein ↑
*[[CT head|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%
*[[LP|CSF]] 
**↑ opening pressure in 80%
**↑ protein/cell counts in 35-50%
*[[Head CT|CT]]: Often negative 
*[[brain MRI|MRV]] (preferred): Intraluminal clot flow voids

==See Also==
*[[Headache]]
*[[Post-Partum Emergencies]]

==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.

[[Category:Neurology]]
[[Category:OBGYN]]
[[Category:Symptoms]]