What is the recommended treatment for postpartum headaches, specifically the use of Compazine (prochlorperazine)?

Management of Postpartum Headaches: Role of Compazine (Prochlorperazine)

Metoclopramide combined with diphenhydramine is more effective than codeine for treating postpartum headaches, while prochlorperazine (Compazine) may be appropriate as monotherapy for acute migraine attacks, particularly in patients with nausea and vomiting. 1, 2

First-Line Treatment Options for Postpartum Headaches

• Acetaminophen (paracetamol) is the first-line medication for postpartum headaches due to its relatively safe profile, with a recommended dose of 1000 mg 3, 4
• NSAIDs such as ibuprofen are recommended by ACOG as first-line treatment for postpartum pain after vaginal delivery 1
• For more severe pain after cesarean delivery, ACOG recommends a stepwise approach starting with acetaminophen and NSAIDs before considering short-acting, low-potency opioids for the shortest duration possible 1

Role of Antiemetics in Postpartum Headache Management

• Prochlorperazine (Compazine) has fair evidence supporting its use as monotherapy for acute migraine attacks, particularly beneficial in patients with nausea and vomiting 1
• Metoclopramide is another antiemetic option that can be used for nausea associated with migraine in the postpartum period 3
• Combination therapy with metoclopramide and diphenhydramine has been shown to be more effective than codeine for treating migraine or tension headache in the postpartum period 2

Diagnostic Approach to Postpartum Headaches

• The PARTUM mnemonic is useful for evaluating postpartum headaches: Pressure (pre-eclampsia), Anaesthetic (post-dural puncture), Reversible (vasoconstriction syndrome), Thrombosis (cerebral venous sinus thrombosis), Use your brain (other causes), Migraine 5
• Tension-type/migraine headache is the most common cause (47%) of postpartum headaches, followed by preeclampsia/eclampsia (24%) and spinal headache (16%) 6
• Persistent headaches that develop >24 hours after delivery require a stepwise evaluation, with cerebral imaging indicated for patients with refractory headache or neurologic deficits 6

Medications to Avoid in Postpartum Period

• Ergotamine and ergot alkaloids are contraindicated during pregnancy and should be used with caution in the postpartum period 1, 3
• Opioids and butalbital-containing medications should be limited due to risks of dependency and medication-overuse headache 1, 3
• Triptans are generally considered safe during breastfeeding but should be used with caution 3, 4, 2

Special Considerations

• Medication overuse headache can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 3
• Rare but serious causes of postpartum headache include cerebral venous thrombosis, hemorrhage, vasculopathy, and lymphocytic hypophysitis - the latter presenting with headache and hyponatremia 6, 7
• For women with frequent and disabling migraines postpartum, propranolol has the best safety profile if preventive medication is required 3

Treatment Algorithm for Postpartum Headaches

1. Rule out preeclampsia in women with hypertension and proteinuria 6
2. For primary headaches without concerning features:
   • Start with acetaminophen 1000 mg 3, 4
   • Add NSAIDs if not contraindicated 1
   • Consider prochlorperazine or metoclopramide for associated nausea or if first-line treatments fail 1, 3
3. For suspected post-dural puncture headache, obtain anesthesia consultation 6
4. For headaches with focal neurologic deficits, severe sudden onset, or failure to respond to initial therapy, obtain urgent neuroimaging 6