Don't Forget Rare Causes of Postpartum Headache! Cases Report and Literature Review

Marco Di Paolo¹, Aniello Maiese¹, Ornella Mangiacasale², Barbara Pesetti³, Simone Pierotti¹, Alice Chiara Manetti¹, Massimiliano dell'Aquila⁴, Angela De Filippis⁵, Emanuela Turillazzi¹

産後6週以内に起こった頭痛や首痛

出産経験者の39-40%が経験する。

頭痛の種類も様々で、

緊張型頭痛；39％

子癇前症/子癇；24%

片頭痛；11％

出血や血栓症などの血管障害性；10％

硬膜穿刺後頭痛(PDPH)；16％

とされている。

Table 1

The differential causes of secondary postpartum headache, helpful elements for diagnosis, and common management. CSF: cerebral spinal fluid; EBP: epidural blood patch; NSAIDs: non-steroidal anti-inflammatory drugs; MRI: magnetic resonance imaging; CTI: computed tomography imaging [20].

Secondary Postpartum Headache Etiologies	Signs and Symptoms	Diagnosis	Treatment
Pre-eclampsia/Eclampsia	Hypertension, headache, and altered mental status until unconsciousness	Clinic with laboratory findings of thrombocytosis, possible alteration of liver function, proteinuria	Pharmacological: blood pressure control with labetalol and nifedipine, antiseizure with phenytoin, diazepam, midazolam, and Magnesium e.v.
PDPH	Postural headache worsening with activity, subsiding in 15 min with supine position after accidental dural puncture (ADP)	Clinical diagnosis of ADP during analgesia overflow of CSF from Touhy needle, or after positioning of epidural catheter for aspiration of CSF or anesthesia after injection of a test dose of anesthetic	If the epidural catheter is inserted, leave in place for 24 h. Keep antalgic position. Avoid dehydration with eventual e.v. supplementation. Pharmacologic: analgesics and NSAIDs Invasive treatment: EBP if pharmacologic treatment fails after 2 weeks [21]
Cerebral venous sinus thrombosis (CVST)	Aspecific headache with possible focal signs, loss of consciousness, and seizure	MRI	Pharmacological: control of seizures and anticoagulation therapy [22]
Subarachnoid Hemorrhage (more common in presence of MAV)	Sudden intense headache unilateral with nausea, neck stiffness, and loss of consciousness	CTI	Possible neurosurgery in selected case
Posterior reversible Encephalopathy syndrome (PRES)	The following can be present: hypertension, headache, vomiting, visual disturbance, altered mental status until unconsciousness, and seizures	CTI MRI	Pharmacologic: to control blood pressure, phenytoin, midazolam, or diazepam; to control seizure, corticosteroids for edema
Cerebral infarction/ischemia	Sudden headache, with vomiting, seizure, and possible focal deficit	Cerebral angiography	Specialist neurologic opinion for management
Meningitis	Fever, neck stiffness, and photophobia. Kernig and Brudzinski signs positive. Petechial rash possible	Lumbar puncture with examination and culture of CSF	Selected antibiotic therapy
Pituitary apoplexia (more common in presence of adenoma)	Retro-orbital headache and possible hormonal insufficiency (adrenocortical insufficiency, hypothyroidism) and diabetes insipidus	MRI and possible laboratory endocrinologic hormonal alteration	Correct hydro-electrolytic imbalance if present. Endocrinologic therapy to supply hormone deficiency. Possible neurosurgery in selected cases [23].