Management of Postpartum Headaches
The management of postpartum headaches requires a systematic diagnostic approach followed by targeted treatment based on the underlying cause, with acetaminophen and NSAIDs as first-line pharmacological options for most benign headaches. 1
Diagnostic Approach: The PARTUM Mnemonic
Postpartum headaches can range from benign to life-threatening conditions. Using the PARTUM mnemonic helps identify the underlying cause 2:
- Pressure (blood pressure for pre-eclampsia/eclampsia)
- Anesthetic (post-dural puncture headache)
- Reversible (vasoconstriction syndrome)
- Thrombosis (cerebral venous sinus thrombosis, ischemic stroke)
- Use your brain (other causes of headache)
- Migraine
Key Diagnostic Considerations
- Timing: Postpartum headaches typically present around 3-4 days after delivery (range 2-32 days) 3
- Neuroimaging: Required when headache is accompanied by:
- Focal neurologic deficits
- Failure to respond to initial therapy
- Non-orthostatic headache developing after initial orthostatic headache
- Headache onset >5 days after suspected dural puncture
- Altered consciousness or seizures (especially in postpartum period) 4
Treatment Based on Etiology
1. Tension-Type/Migraine Headache (47% of cases) 3
First-line treatments:
Non-pharmacological approaches:
- Relaxation techniques
- Adequate sleep hygiene
- Ice packs
- Regular meals and hydration 1
Pharmacological options:
For moderate to severe migraines not responding to NSAIDs:
- Sumatriptan: Considered safe during breastfeeding with low transfer into breast milk 1
- Metoclopramide: Compatible with breastfeeding, helps with nausea 1
Combination therapy:
- Metoclopramide and diphenhydramine may be more effective than codeine for migraine or tension headache 5
2. Post-Dural Puncture Headache (16% of cases) 3
- Conservative management initially
- Epidural blood patch (EBP) for refractory cases
3. Preeclampsia/Eclampsia-Related Headache (24% of cases) 3
- Blood pressure control
- Magnesium sulfate for seizure prophylaxis
- Delivery is definitive treatment
Special Considerations
Medications to Avoid or Use with Caution
- Aspirin: Associated with Reye's syndrome, use with caution 1
- Codeine and Opioids: Risk of infant sedation, respiratory depression, and dependency 1
- Butalbital-containing medications: Should not be used during pregnancy 1
Warning Signs Requiring Urgent Evaluation
- Focal neurological deficits
- Seizures
- Altered mental status
- Fever with headache (consider meningitis) 2
- Headache unresponsive to usual therapy 3
Preventive Treatment
Preventive treatment should only be considered in severe cases with at least three prolonged and debilitating attacks per month that don't respond to symptomatic therapy:
- Propranolol: 80-160 mg once or twice daily (extended-release) is the first choice when prevention is needed 1
Monitoring
- Monitor for medication overuse headache with frequent use of acute medications (≥15 days/month for ≥3 months) 1
- Monitor infants for unusual drowsiness or poor feeding with any medication use 1
Pitfalls to Avoid
- Misdiagnosing serious causes as benign headaches: Up to 68% of patients requiring neuroimaging have abnormal findings 3
- Failing to consider preeclampsia in women with hypertension and proteinuria 3
- Delaying neuroimaging in patients with focal neurologic deficits or refractory headache 4
- Performing EBP in febrile patients or those with signs of infection 4
By following this systematic approach to diagnosis and treatment, most postpartum headaches can be effectively managed while ensuring that potentially serious causes are not missed.