What is the most likely cause of a severe headache in a postpartum patient who had an uncomplicated cesarean section (C-section) with epidural anesthesia?

Post-Cesarean Section Severe Headache: Most Likely Diagnosis

The most likely cause of this patient's severe headache is a spinal fluid leak (post-dural puncture headache) from accidental dural puncture during epidural placement. 1

Clinical Reasoning

Why Spinal Fluid Leak (Answer C) is Most Likely

• Post-dural puncture headache (PDPH) occurs in 52-60% of obstetric patients after accidental dural puncture, which happens in 0.4-1.5% of all attempted neuraxial blocks 1
• The patient had epidural anesthesia for her C-section, placing her at risk for this complication 1
• PDPH typically presents as severe headache within 5 days of the procedure 2
• The headache is characteristically postural (worsens upright, improves lying flat) and often accompanied by neck stiffness 2
• Her vital signs show mild tachycardia (HR 110) which is consistent with CSF leak, but otherwise stable hemodynamics 2

Why NOT the Other Options

Eclampsia (Answer A) is unlikely because:

• Eclampsia requires seizures by definition, which are not mentioned 1
• Her blood pressure is only mildly elevated (140/78), not severely hypertensive 1
• The procedure was uncomplicated with minimal blood loss 1

Preeclampsia (Answer B) is unlikely because:

• While her BP is slightly elevated, this alone doesn't explain severe headaches requiring ICU transfer 1
• The C-section was described as uncomplicated, suggesting no prior diagnosis of preeclampsia 1
• Preeclampsia headaches are typically not the sole presenting feature requiring ICU admission 1

Hypovolemic shock (Answer D) is definitively ruled out because:

• Her estimated blood loss was only 100 mL, which is minimal 1
• Her vital signs show adequate perfusion: BP 140/78, O2 sat 99% 1
• While she has mild tachycardia, her blood pressure is normal-to-elevated, not hypotensive 1

Immediate Management Considerations

Conservative management for first 72 hours includes:

• Maintain adequate oral hydration 2
• Multimodal analgesia with acetaminophen and NSAIDs 2
• Caffeine administration (up to 900 mg/day) within first 24 hours of symptoms 2
• Short-term opioids if multimodal analgesia ineffective 2

If symptoms persist beyond 72 hours:

• Epidural blood patch (EBP) should be performed without need for initial imaging studies 2
• EBP should be directed at the level of the known dural puncture 2
• Effectiveness is evident by marked pain decrease approximately 4 hours post-procedure 2

Critical Pitfalls to Avoid

• Do not delay definitive treatment with unnecessary imaging during first 72 hours 2
• Ensure adequate follow-up until headache resolves to monitor for complications including chronic headache or cerebral venous sinus thrombosis 1, 2
• Watch for red flags requiring urgent neuroimaging: worsening symptoms despite EBP, new focal neurological symptoms, or change in headache nature 2