What is the appropriate management for postpartum headaches?

Management of Postpartum Headaches

Start with acetaminophen (paracetamol) 1000 mg as first-line treatment for postpartum headaches, with ibuprofen and sumatriptan also considered safe during breastfeeding. 1, 2, 3

Initial Diagnostic Approach

Before treating, rapidly exclude life-threatening causes using the PARTUM mnemonic 4:

• Pressure: Check blood pressure for preeclampsia/eclampsia (new headache with hypertension should be considered preeclampsia until proven otherwise) 1, 3
• Anaesthetic: Assess for post-dural puncture headache (positional headache worse when upright, better when supine, typically within 5 days of neuraxial procedure) 1, 4
• Reversible vasoconstriction syndrome 4
• Thrombosis: Consider cerebral venous sinus thrombosis or ischemic stroke, especially with focal neurological deficits 1, 4
• Use your brain: Other causes including meningitis, subdural hematoma, lymphocytic hypophysitis 4, 5
• Migraine: Most common benign cause (>75% of postpartum headaches are primary headache disorders) 4, 6

Red flags requiring urgent neuroimaging (MRI preferred): focal neurological deficits, altered mental status, seizures, persistent headache unresponsive to initial therapy, or headache with fever and meningismus 1, 7

Pharmacological Treatment Algorithm

Step 1: First-Line Therapy

• Acetaminophen 650-1000 mg every 4-6 hours (maximum 4 g/day) 2, 3
• Ibuprofen 400-800 mg every 6 hours (maximum 2.4 g/day) - safe during breastfeeding 1, 2, 3
• Naproxen sodium 275-550 mg every 6 hours (maximum 1.5 g/day) 1

Step 2: Add Antiemetic if Nausea Present

• Metoclopramide (Reglan) 10 mg orally or IV - particularly useful for migraine-type headaches with nausea 1, 2
• Contraindications: pheochromocytoma, seizure disorder, GI bleeding/obstruction 2
• Watch for dystonic reactions, restlessness, drowsiness 2

Step 3: For Severe Migraine Unresponsive to Above

• Sumatriptan (various formulations) - safe during breastfeeding, most safety data among triptans 1, 2, 3
• Consider non-oral triptan formulations if severe nausea/vomiting present 1

Step 4: Adjunctive Therapy

• Diphenhydramine for nighttime use if sleep disturbance contributing, though caution with sedation affecting newborn care 2
• Prochlorperazine (Compazine) can effectively relieve headache pain and nausea 1, 8

Critical Medications to AVOID

Never use in postpartum period:

• Opioids (meperidine, butorphanol) - risk of dependency, medication-overuse headache, and eventual loss of efficacy 1, 2, 8, 3
• Butalbital-containing analgesics - same risks as opioids 1, 2, 8, 3
• Ergotamine and ergot alkaloids - contraindicated, use with extreme caution only 2, 8, 3

Preventive Therapy (If Frequent Disabling Migraines)

Propranolol 80-160 mg daily in long-acting formulations has the best safety profile for breastfeeding mothers requiring preventive treatment 1, 8, 3

Alternative if propranolol contraindicated: Amitriptyline 10-100 mg at night 1

Medication Overuse Headache Prevention

Critical thresholds to avoid:

• NSAIDs: ≥15 days per month 1, 2, 8, 3
• Triptans: ≥10 days per month 1, 2, 8, 3

If approaching these thresholds, initiate preventive therapy rather than continuing acute treatment 1

Special Clinical Scenarios

Post-dural puncture headache: Requires anesthesia consultation; epidural blood patch needed in approximately 80% of cases where conservative management fails 1

Preeclampsia-related headache: Requires antihypertensive management and magnesium sulfate, not simple analgesics 1

Neurological deficits present: 68% of postpartum patients requiring cerebral imaging due to focal deficits or refractory headache have abnormal findings; 10% have serious pathology (hemorrhage, thrombosis, vasculopathy) 7

Common Pitfalls

• Discharging patients with simple analgesics without excluding secondary causes - median onset of postpartum headache is 2-3 days, often after hospital discharge 7, 6
• Missing preeclampsia in women with new-onset headache and hypertension 1, 3
• Failing to obtain neuroimaging in patients with persistent headache despite appropriate therapy 7
• Using opioids as first-line therapy rather than NSAIDs and acetaminophen 1, 2, 8