SAN FRANCISCO — Evaluating persistent headache that presents more than 24 hours after delivery requires a stepwise, multidisciplinary approach, Dr. Caroline Stella said at the annual meeting of the Society for Maternal-Fetal Medicine.
Postpartum headache affects 11%–80% of women after delivery, and usually is benign. Little has been known about headaches that start more than a day after delivery.
Dr. Stella of the University of Cincinnati and her associates retrospectively studied records for 95 women with severe headaches that started 25 hours to 32 days post partum and were unresponsive to usual doses of analgesics.
Approximately half of the women (47 patients) ultimately were diagnosed with tension-type or migraine headaches, and all responded to higher doses of analgesics or narcotics.
Twenty-three women (24%) with headaches caused by preeclampsia or eclampsia were treated with magnesium sulfate or antihypertensives; one had a cerebral venous thrombosis, and one had a subarachnoid hemorrhage.
Fifteen women (16%) had a final diagnosis of spinal headache. All received an anesthesiology consultation and initially were treated with analgesics. Twelve patients (13%) eventually required a blood patch. Headaches caused by other abnormalities in 10 women (11%) were treated with anticonvulsants, anticoagulants, or a dopamine antagonist.
Some patients had overlapping diagnoses. In 78 women, the headaches started while they were in the hospital; the other 17 were readmitted after postpartum discharge. Cesarean deliveries had been performed in 28 women.
Of the 95 women, 22 (23%) underwent cerebral imaging studies. Indications for imaging included persistent visual changes in 14 patients, focal neurologic deficits in 8, refractory headache in 8, and other reasons.
Neurologic symptoms other than headache resolved in 20 of the 22 women. Two patients were left with residual facial droop. No patients died.
On the basis of the study's findings, Dr. Stella and her associates recommended the following algorithm for work-up of postpartum headache presenting after 24 hours.
If neurologic deficits are present, perform cerebral imaging right away. If no neurologic deficits are present in a normotensive patient without proteinuria, treat for presumed migraine or tension-type headache.
If that therapy doesn't work and the patient has a history of regional anesthesia placement, consider the diagnosis of postdural puncture headache. Give intravenous fluids and analgesia, and consider administering a blood patch. If the headache still doesn't respond to therapy, perform cerebral imaging.
Presume a diagnosis of preeclampsia or eclampsia in women with hypertension or proteinuria and administer magnesium sulfate and antihypertensive agents. If the headache is unresponsive, perform cerebral imaging.
Eclampsia increased the risk for cognitive dysfunction years later in a separate case-control study of 87 women presented in a poster session by Annet M. Aukes, a medical student at the University of Groningen (the Netherlands).
From 6 to 8 years after their eclampsia episodes, 29 women were matched by age and year of pregnancy with formerly preeclamptic women and normotensive controls. All completed a validated Cognitive Failures Questionnaire designed to assess the likelihood of committing a cognitive error in an everyday task.
The women with a history of eclampsia scored significantly worse, compared with preeclamptic women or controls. The paradigm that eclamptic women can expect a full recovery should be reevaluated, she said in an interview.
“It's very important that these women are treated adequately right away when they come in with headaches so we can prevent more eclamptic seizures,” Ms. Aukes said.
These women need support months and years later to understand that their dysfunction is not psychological but caused by white matter lesions, she added.
MRIs of a patient's brain show cerebral edema (red arrows, left) in the occipital lobes and, on follow-up, complete resolution of the edema (red arrows, right). Photos courtesy Dr. Caroline Stella
