By Dara G. Jamieson, MD
Associate Professor of Clinical Neurology, Weill Cornell Medical College
Dr. Jamieson reports no financial relationships relevant to this field of study.
Consultation for acute postpartum headache resulted in the diagnosis of a secondary cause of headache in almost three out of four women, with almost half of the secondary headaches due to a hypertensive disorder of pregnancy or to cerebrovascular disease.
Vgontzas A, Robbins MS. A hospital-based retrospective study of acute postpartum headache Headache 2018 Feb. 15; doi: 10.1111/head.13279. [Epub ahead of print].
In the postpartum period, changes in hormones, blood volume, and spinal fluid dynamics can precipitate headache. Vgontzas et al reviewed the causes of acute headache in postpartum women, with the goal of distinguishing between primary and secondary headache types. The retrospective study of consecutive postpartum (up to six weeks after delivery) women 18 years of age and older who received a neurological consultation requested by the obstetrical service or the emergency department for headache was undertaken at a large urban tertiary-care hospital (Montefiore Medical Center, Bronx) between July 1, 2009, and Dec. 31, 2016. Demographic and obstetrical data were gleaned from chart review. Headaches were diagnosed according to the International Headache Society classification criteria and were segregated into primary and secondary headache groups. The 63 women with postpartum headache had a mean age of 29.5 years. One-third of the women were Hispanic, 30% were Black/African-American, 9.5% were white/Caucasian, and 3.2% were Asian. Overall, 54% of the women had a past headache history.
Of the 63 women who presented with acute postpartum headache, 17 (27.0%) were diagnosed with a primary headache disorder and 46 (73.0%) were diagnosed with a secondary headache disorder. A prior history of headaches was noted in more women in the primary headache group compared to in the secondary headache group (76.4 vs. 45.7; P = 0.045), but no patient characteristics were significantly different between the two headache groups. The headaches occurred 4.7 ± 7.3 days postpartum. Migraine was the predominant primary headache type (76.5%). Tension-type headache, occipital neuralgia, cervicogenic headache, and primary thunderclap headache (with a history of migraine and negative evaluation) each were diagnosed in four patients. Secondary headache types were postdural puncture headache (PDPH; 45.7%), uncomplicated postpartum preeclampsia (26.1%), and a diverse group of cerebrovascular headache disorders (21.7%), including pituitary apoplexy, cerebral venous thrombosis, Moyamoya, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, and vertebral artery dissection. Patients with PDPH presented within 24 hours of delivery with diffuse head localization of the pain. Significant factors associated with having a secondary headache included a lack of a prior headache history (54.3% vs. 23.6%), an orthostatic pattern of the pain (43.5% vs. 5.9%), and abnormal brain imaging (40.5% vs. 0%).
The authors noted that for consultations in their institution, secondary headache comprised almost 75% of all acute headache diagnoses during the postpartum period, compared to only 35% of diagnoses of secondary headache occurring during pregnancy itself. The most common secondary headache disorder diagnosed was PDPH; however, headaches attributable to pre-eclampsia or cerebrovascular disorders comprised half of all secondary headaches occurring in the six-week period after delivery. The patients whose headache developed more than 24 hours after delivery were more likely to have a migraine or a non-PDPH secondary headache type. The high rate of secondary headaches in this review may reflect the sample for whom urgent neurology consultation was requested. Vgontzas et al noted that prior prospective studies of headache in postpartum women overall have reported very low rates of secondary headache. They concluded that if the acute postpartum headache does not fit the criteria for PDPH, then neuroimaging, as well as monitoring for acute hypertensive disorders of pregnancy, is indicated.
COMMENTARY
In this review of 7.5 years of urgent consultation for acute postpartum headache, a secondary cause of the headache was found in almost three out of four women. Since a secondary cause of headache generally dictates some specific intervention, this differentiation is crucial. The high percentage of secondary postpartum headaches in this recent time frame in the authors’ institution may reflect the presence of risk factors for some vascular disorders of pregnancy, including increased maternal age and Black/African-American ethnicity, as well as the prevalence of epidural/spinal anesthesia for delivery.
The most common secondary headache, PDPH, has characteristics of timing (hours after the dural puncture) and exacerbation (worse with change in position between upright and standing) that can indicate the diagnosis even without brain imaging. Generally, the headache with PDPH is self-limited, and women usually need only reassurance, hydration, and possibly a blood patch before the headache dissipates. However, the diagnosis and treatment of hypertensive disorders of pregnancy such as pre-eclampsia, eclampsia, and HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome, which often are heralded by a headache, is critical to prevent the rare but devastating complications of intraparenchymal hemorrhage and ischemic stroke. A prior history of migraine headaches should not diminish the concern about a headache due to hypertensive disorders of pregnancy, as a migraine history is a risk factor. Other cerebrovascular disorders seen in the peripartum period also may need immediate diagnosis and specific treatment, such as anticoagulation for cerebral venous thrombosis. This high secondary headache risk emphasizes the importance of a detailed headache history and brain imaging when consulted for an acute postpartum headache. If a woman in the postpartum period has an acute headache that does not fit easily into a primary headache or PDPH category, then an MRI of the brain should be obtained and her blood pressure should be closely monitored and treated appropriately.
