Postpartum headache

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 2/2 CSF leak
• Incidence: 0.5-1.5% of women receiving epidural anesthesia
  • Can occur in women who have not received epidural 2/2 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 pts
  • MRI: Prominent T2-weighted and FLAIR, often in parieto-occipital lobes
  • Intracerebral hemorrhage in 15% of pts

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 pts 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

• Headache
• Post-Partum Emergencies

References

1. 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.
2. 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.
3. Klein AM, Loder E. Postpartum headache. International journal of obstetric anesthesia 2010;19:422-30.
4. 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.