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)

Postpartum Emergencies

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
    • 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

  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.