When are postpartum headaches most common?

Timing of Postpartum Headaches

Postpartum headaches are most common within the first week after delivery, with a median onset of two days postpartum. 1

Epidemiology and Timing

• Approximately 39% of women experience headaches or neck/shoulder pain in the postpartum period 1
• The typical timeline for postpartum headaches:
  • Median onset: 2 days after delivery
  • Range: 0-6 days (first to third quartiles)
  • Median duration: 4 hours (range: 2-24 hours)
  • Most headaches (>75%) are primary headaches (tension-type or migraines)

Types and Causes of Postpartum Headaches

The PARTUM mnemonic helps identify common causes 2:

1. Pressure: Pre-eclampsia/eclampsia (24% of postpartum headaches) 3
2. Anaesthetic: Post-dural puncture headache (16-45.7% of cases) 3, 4
3. Reversible: Vasoconstriction syndrome
4. Thrombosis: Cerebral venous sinus thrombosis, ischemic stroke
5. Use your brain: Other causes
6. Migraine: Most common primary headache (47% of cases are tension-type/migraine) 3

Risk Factors for Postpartum Headaches

Several factors increase the risk of developing postpartum headaches 1:

• Known inadvertent dural puncture (6.36 times higher risk)
• Previous headache history (1.57-2.25 times higher risk depending on frequency)
• Multiparity (1.37 times higher risk)
• Increasing age (3% increased risk per year)

Warning Signs Requiring Urgent Evaluation

Certain features warrant immediate neuroimaging and further evaluation:

• Focal neurologic deficits
• Headache refractory to usual therapy
• Presentation with severe, sudden-onset headache
• Abnormal vital signs, particularly hypertension with proteinuria

Management Approach

1. First 24 hours: Rule out post-dural puncture headache, which typically lacks side predominance 4
2. Beyond 24 hours: Consider both primary and secondary causes
3. For severe headaches: Nearly 75% of women requiring neurological consultation have secondary headaches, with almost half attributed to preeclampsia or cerebrovascular disorders 4

Treatment Options

For primary headaches during postpartum and breastfeeding 5:

• Combination metoclopramide and diphenhydramine may be more effective than codeine
• Triptans may not be associated with adverse fetal/child effects
• Low-dose aspirin appears safe
• Paracetamol (acetaminophen) remains the preferred acute medication during the postpartum period and while breastfeeding 6

Important Considerations

• Most postpartum headaches are first noted after discharge from hospital 1
• Only a small percentage (4%) of postpartum headaches are incapacitating 1
• A multidisciplinary approach involving obstetrics, anesthesia, and neurology may be necessary for complex cases 3
• Women with no prior headache history who develop acute severe postpartum headache should undergo neuroimaging to rule out cerebrovascular etiologies 4

Understanding the typical timing and patterns of postpartum headaches is crucial for appropriate diagnosis and management to reduce maternal morbidity and improve quality of life.