Don't Forget Rare Causes of Postpartum Headache! Cases Report and Literature Review
Marco Di Paolo 1, Aniello Maiese 1, Ornella Mangiacasale 2, Barbara Pesetti 3, Simone Pierotti 1, Alice Chiara Manetti 1, Massimiliano dell'Aquila 4, Angela De Filippis 5, Emanuela Turillazzi 1
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]. |
本文では、PDPHの2症例が報告。
産後の頭痛では、二次性頭痛の可能性が高くなる傾向にあるとのこと。
緊張性頭痛の頻度が最も高いが、それにそぐわない場合、二次性頭痛の可能性を考慮して対応する。