Differential Diagnosis for a 21-year-old Postpartum Woman with Severe Headache, Nausea, and Vomiting
- Single most likely diagnosis:
- Post-dural puncture headache (PDPH): This is the most likely diagnosis given the patient's recent epidural placement and removal, followed by the onset of a severe headache that improves with lying down and worsens with standing. The headache's postural nature is a hallmark of PDPH.
- Other Likely diagnoses:
- Migraine: Although less likely given the postural component of the headache, migraines can be severe and are common in women of childbearing age. However, the improvement with lying down is not typical for migraines.
- Tension headache: Could be considered but is less likely due to the severity of the headache and its postural nature.
- Postpartum preeclampsia: Although the patient had gestational hypertension, the current symptoms do not strongly suggest preeclampsia, especially without significant hypertension or proteinuria mentioned. However, it's a consideration in the postpartum period.
- Do Not Miss diagnoses:
- Subarachnoid hemorrhage: Although unlikely, given the lack of "thunderclap" headache description, sudden onset, or loss of consciousness, it's crucial to consider due to its high morbidity and mortality. The presence of neck stiffness could suggest meningismus, which might be seen in subarachnoid hemorrhage.
- Meningitis: The presence of neck stiffness and severe headache could suggest meningitis, especially if the patient had a fever, which is not significantly elevated here. However, the postural nature of the headache and lack of other infectious symptoms make this less likely.
- Venous thromboembolism (VTE): Given the patient's recent pregnancy and the presence of pitting edema, VTE should be considered, although it does not directly explain the headache. However, pulmonary embolism can cause sudden onset of symptoms, including headache, due to hypoxia or hypertension.
- Rare diagnoses:
- Spontaneous intracranial hypotension: This condition can cause postural headaches similar to PDPH but without a clear history of dural puncture. It's less likely given the recent epidural placement.
- Cerebral venous sinus thrombosis: A rare condition that can occur postpartum, characterized by headache, but often accompanied by other neurological deficits or signs of increased intracranial pressure, which are not prominently featured in this case.