What are the appropriate treatments for postpartum headaches?

Postpartum Headache Management

For postpartum headaches, start with acetaminophen 650-1000 mg every 4-6 hours as first-line therapy, but first rapidly exclude life-threatening causes using blood pressure assessment (preeclampsia), history of neuraxial procedures (post-dural puncture headache), and neurological examination for focal deficits (stroke, thrombosis, hemorrhage). 1

Immediate Diagnostic Priorities

Before treating any postpartum headache, systematically exclude dangerous causes:

• Check blood pressure immediately - A new headache with hypertension should be considered preeclampsia/eclampsia until proven otherwise and requires antihypertensive management plus magnesium sulfate, not simple analgesics 2, 1
• Assess for post-dural puncture headache (PDPH) - Positional headache (worse upright, better supine) within 5 days of epidural or spinal anesthesia, often with neck stiffness or hearing symptoms 3, 1
• Perform focused neurological examination - Any focal deficits, altered mental status, or severe refractory headache mandates neuroimaging, as 68% of imaged patients in one series had abnormal findings including hemorrhage, thrombosis, or vasculopathy 4

The mean onset of significant postpartum headache requiring hospitalization is 3.4 days after delivery (range 2-32 days), so remain vigilant beyond the immediate postpartum period 4.

First-Line Pharmacological Treatment

Acute Therapy for Benign Headaches

Acetaminophen (paracetamol) 650-1000 mg every 4-6 hours (maximum 4 g/day) is the safest first-line option during breastfeeding 2, 5, 1

Ibuprofen 400-800 mg every 6 hours (maximum 2.4 g/day) is safe during breastfeeding and recommended as first-line for postpartum pain after vaginal delivery 5, 1

Sumatriptan is safe during breastfeeding for severe migraine unresponsive to acetaminophen or NSAIDs 2, 5, 1

Critical Medications to AVOID

Never use opioids (meperidine, butorphanol) or butalbital-containing medications in the postpartum period - These carry significant risks of dependency, medication-overuse headache, rebound headaches, and eventual loss of efficacy 2, 5, 1

Avoid ergotamine derivatives and dihydroergotamine - These are contraindicated due to potential harm 2, 5

Specific Clinical Scenarios

Post-Dural Puncture Headache (PDPH)

• Request anesthesia consultation for suspected PDPH based on positional characteristics 1
• Conservative management first: bed rest, hydration, caffeine, analgesics 3
• Epidural blood patch is required in approximately 80% of cases where conservative management fails and remains the definitive treatment 1
• PDPH can lead to serious complications including chronic headache, subdural hematoma, and cerebral venous sinus thrombosis if untreated 3

Preeclampsia/Eclampsia-Related Headache

This requires antihypertensive management and magnesium sulfate rather than analgesics alone 1. New-onset headache with hypertension in the postpartum period demands urgent evaluation 2.

Refractory Headache Requiring Imaging

Obtain cerebral imaging (CT or MRI) for:

• Focal neurological deficits 4, 6
• Failure to respond to initial therapy within 24-48 hours 4
• Altered mental status or seizures 6, 7
• "Thunderclap" sudden-onset severe headache (consider reversible cerebral vasoconstriction syndrome or subarachnoid hemorrhage) 7

In one retrospective series, 10 of 95 hospitalized postpartum headache patients had serious cerebral pathology including hemorrhage, thrombosis, or vasculopathy 4.

Preventive Therapy for Frequent Migraines

If preventive medication is required postpartum (≥2 attacks per month producing disability lasting ≥3 days per month), propranolol 80-160 mg daily in long-acting formulations is the first-choice medication due to superior safety profile during breastfeeding 5, 1

Amitriptyline is the second-line option if propranolol is contraindicated (asthma, cardiac failure, Raynaud disease, atrioventricular block, depression) 5, 1

Avoid topiramate, candesartan, and sodium valproate - These are contraindicated due to adverse effects and transfer into breast milk 2, 5

Medication Overuse Headache Prevention

Critical thresholds to avoid:

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

Exceeding these thresholds leads to medication overuse headache, which presents as migraine-like daily headaches or marked increase in migraine frequency 8.

Non-Pharmacological Interventions

Before or alongside pharmacological treatment:

• Maintain adequate hydration and regular meals 2, 5
• Ensure consistent sleep patterns (7-9 hours) 2, 5
• Engage in appropriate physical activity 2, 5
• Identify and avoid migraine triggers 2, 5
• Provide quiet, dark environment for acute migraine 2

Common Pitfalls to Avoid

Do not discharge patients with simple analgesics without excluding secondary causes, especially in the first week postpartum when serious pathology is most likely 1, 4

Do not miss preeclampsia in women with new-onset headache and hypertension - This is the most critical diagnostic error 1

Do not use opioids as first-line therapy rather than acetaminophen and NSAIDs 1

Do not assume all postpartum headaches are benign - Tension-type/migraine headaches account for only 47% of cases requiring hospitalization, while preeclampsia (24%), spinal headache (16%), and serious cerebral pathology (11%) comprise the remainder 4