We need you! Join our contributor community and become a WikEM editor through our open and transparent promotion process.
Postpartum headache
From WikEM
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
Postpartum Emergencies
- Amniotic fluid embolus
- Chorioamnionitis
- Eclampsia
- Postpartum endometritis
- Postpartum headache
- HELLP syndrome
- Postpartum hemorrhage
- Mastitis
- Peripartum cardiomyopathy
- Preeclampsia
- Retained products of conception
- 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
- 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.
