Postpartum Headache

Postpartum headache is head pain in the first 6 weeks after birth, and it is common. Most are tension or migraine headaches, but dangerous causes include postpartum preeclampsia and eclampsia, post dural puncture headache after spinal or epidural anaesthesia, cerebral venous thrombosis, reversible cerebral vasoconstriction, stroke, meningitis, pituitary apoplexy and intracranial haemorrhage. It matters because severe or new headache after birth is a warning of life-threatening disease.

• Risk factors: preeclampsia, spinal or epidural anaesthesia with accidental dural puncture, caesarean section, previous migraine, sleep loss, dehydration, caffeine withdrawal, anaemia, postpartum haemorrhage (pituitary).
• Post dural puncture headache appears 1 to 5 days after puncture.
• Postpartum preeclampsia can start up to 6 weeks after birth.

Women have headache that varies by cause:

• Tension headache is band-like and mild.
• Migraine is pulsating with nausea, light and noise sensitivity.
• Post dural puncture headache is worse upright and eases lying flat.
• Preeclampsia headache is severe and frontal with visual disturbance and epigastric pain.
• Cerebral venous thrombosis causes persistent headache, seizures and focal signs.
• Blood pressure at or above 140/90 mmHg, hyperreflexia and clonus in preeclampsia.
• Neck stiffness, fever, seizures, focal deficit or altered consciousness suggest a serious cause.
• Differential diagnosis: tension headache, migraine, postpartum preeclampsia or eclampsia, post dural puncture headache, cerebral venous thrombosis, reversible cerebral vasoconstriction syndrome, stroke, meningitis, pituitary apoplexy, sinusitis, caffeine withdrawal, hypoglycaemia, anaemia, intracranial haemorrhage.
• Complications: seizures, stroke, subdural haematoma, cerebral venous thrombosis, chronic headache, hearing loss, persistent visual loss, maternal death.

The approach is blood pressure and neurological examination first, then targeted tests for dangerous causes.

• Blood pressure on every woman with headache; neurological examination including fundi, visual fields, neck stiffness and reflexes.
• Urine protein, full blood count with platelets, liver enzymes, creatinine, uric acid; glucose; malaria rapid test.
• CT head, then MRI with venography for new severe headache, seizures, focal signs or persistent headache; CT venography if MRI is unavailable.
• Lumbar puncture if fever and neck stiffness; MRI pituitary and cortisol if headache with visual loss after haemorrhage.

The principle is to treat dangerous causes at once and to treat benign headache with simple analgesia and avoidance of triggers.

• Supportive: blood pressure monitoring 4-hourly in preeclampsia; hydration with 2 to 3 litres of fluid daily; rest in a quiet dark room; regular meals and sleep. Limit caffeine to 200 mg daily outside treatment of post dural puncture headache. Lie flat for comfort in post dural puncture headache (bed rest does not prevent it). Breastfeeding continues.
• Pharmacological: paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); ibuprofen 400 mg oral 8-hourly with food for 3 to 5 days if blood pressure is controlled and kidney function normal.
• Migraine: metoclopramide 10 mg oral or IV 8-hourly plus sumatriptan 50 mg oral repeated once after 2 hours (maximum 100 mg daily; compatible with breastfeeding).
• Post dural puncture headache: caffeine 300 mg oral every 6 to 8 hours for up to 3 days (maximum 600 mg daily), fluids, paracetamol and ibuprofen.
• Preeclampsia: magnesium sulphate 4 g IV over 20 minutes then 1 g/hour IV for 24 hours.
• Preeclampsia blood pressure control: labetalol 20 mg IV then 40 mg after 10 minutes and 80 mg every 10 minutes (maximum total 220 mg) or nifedipine 10 mg oral repeated after 30 minutes for blood pressure at or above 160/110 mmHg. Then nifedipine modified release 30 mg oral 12-hourly (maximum 120 mg daily) to keep blood pressure below 150/100 mmHg.
• Cerebral venous thrombosis: enoxaparin 1 mg/kg subcutaneous 12-hourly then warfarin 5 mg oral once daily to INR 2.0 to 3.0 for at least 3 to 6 months.
• Meningitis: ceftriaxone 2 g IV 12-hourly with dexamethasone 10 mg IV 6-hourly for 4 days.
• Migraine prevention: propranolol 40 mg oral 12-hourly increased to 80 mg 12-hourly.
• Procedures: epidural blood patch with 15 to 20 mL of the woman's own blood, done after 24 to 48 hours when post dural puncture headache persists and conservative treatment fails. Sphenopalatine ganglion block is an alternative. Lumbar puncture for suspected meningitis after a CT scan if there are focal signs.
• Special groups: women with hypertension or preeclampsia avoid NSAIDs when creatinine is raised or platelets are low, and avoid triptans and ergot drugs until blood pressure is controlled.
• Women with cerebral venous thrombosis and seizures have levetiracetam 500 mg oral 12-hourly increased to 1000 mg 12-hourly.
• Breastfeeding is compatible with paracetamol, ibuprofen, sumatriptan, metoclopramide and propranolol.
• Red flags: blood pressure at or above 160/110 mmHg, seizure, visual loss, confusion, focal weakness, fever with neck stiffness, thunderclap onset, post dural puncture headache not improving after 72 hours of treatment, persistent vomiting, sudden loss of consciousness.
• Follow-up: review within 24 hours if admitted; blood pressure and urine protein checks twice weekly for 2 weeks in preeclampsia; review at 6 weeks; MRI review if headache persists beyond 2 weeks; migraine and blood pressure follow-up at 3 months.
• Counsel about contraception without oestrogen in women with migraine with aura or hypertension.