What is the differential diagnosis and management of postpartum headaches?

Postpartum Headache Differential Diagnosis

Primary Diagnostic Framework

Use the PARTUM mnemonic to systematically exclude life-threatening causes before attributing headache to benign etiologies 1, 2. This structured approach prioritizes rapid identification of conditions with significant morbidity and mortality.

PARTUM Mnemonic Components

• P - Pressure (Preeclampsia/Eclampsia): A new headache with hypertension should be considered preeclampsia until proven otherwise 1, 2. Check blood pressure and assess for proteinuria, visual changes, and right upper quadrant pain 1.

• A - Anaesthetic (Post-Dural Puncture Headache): Assess for positional headache that is worse when upright and better when supine, typically occurring within 5 days of neuraxial procedure 3, 1. Often accompanied by neck stiffness and subjective hearing symptoms 3.

• R - Reversible Cerebral Vasoconstriction Syndrome: Consider in patients with thunderclap headache or recurrent severe headaches 2.

• T - Thrombosis (Cerebral Venous Sinus Thrombosis, Ischemic Stroke): Mean onset is 3.4 days postpartum but can occur up to 32 days after delivery 4. Initially may present as non-specific headache that becomes refractory to treatment 5, 6.

• U - Use Your Brain (Other Causes): Include meningitis, subdural hematoma, intracranial hemorrhage, and space-occupying lesions 2, 7.

• M - Migraine/Tension-Type Headache: Most common benign cause, accounting for approximately 47% of postpartum headaches requiring hospitalization 4, 7.

Critical Red Flags Requiring Urgent Neuroimaging

Focal neurological deficits, visual changes, alterations in consciousness, or seizures should prompt immediate neuroimaging to evaluate alternative diagnoses 3. These findings have moderate certainty evidence for requiring brain imaging 3.

Additional Imaging Indications

• Non-orthostatic headache that develops after initial orthostatic headache 3.
• Headache onset more than 5 days after suspected dural puncture 3.
• Headache refractory to usual therapy despite appropriate initial management 4.
• Progressive worsening of headache despite conservative treatment 5, 6.

Specific Differential Diagnoses

Post-Dural Puncture Headache (PDPH)

• Presentation: Postural headache worse when upright, better supine, typically within first 5 days of dural puncture 3.
• Associated symptoms: Neck stiffness, subjective hearing symptoms 3.
• Complications: Can be associated with subdural hematoma and cerebral venous sinus thrombosis 3.
• Management: Approximately 80% require epidural blood patch when conservative management fails 1.

Preeclampsia/Eclampsia

• Key feature: New headache with hypertension in postpartum period 1, 2.
• Management: Requires antihypertensive management and magnesium sulfate, not simple analgesics 1.
• Timing: Can occur up to 6 weeks postpartum 2.

Cerebral Venous Sinus Thrombosis (CVST)

• Presentation: Initially may mimic benign headache or PDPH, becoming continuous and refractory to treatment 5, 6.
• Associated features: May develop ataxia, hemiparesis, seizures 5.
• Diagnosis: Requires CT or MR venography 6.
• Critical pitfall: Can be misdiagnosed as PDPH when headache initially appears positional 5.

Meningitis

• Presentation: Worsening headache with pyrexia and signs of meningism 2.
• Risk factors: Recent epidural placement, though rare 2.
• Diagnosis: Lumbar puncture when clinically suspected and no contraindications 2.

Primary Headache Disorders

• Migraine and tension-type headache: Most common overall cause (47% of hospitalized cases) 4.
• Characteristics: Absence of red flag features, normal neurological examination 7.
• Timing: Can be triggered by hormonal shifts, sleep deprivation, stress of delivery 7.

Diagnostic Algorithm

Step 1: Immediate Assessment (Within Minutes)

• Check vital signs, particularly blood pressure for preeclampsia 1, 2.
• Perform focused neurological examination looking for focal deficits, altered consciousness, visual changes 3.
• Review obstetric history for neuraxial procedures, hypertensive disorders 2, 7.

Step 2: Risk Stratification

High-risk features requiring immediate imaging 3, 4:

• Focal neurological deficits
• Seizures
• Altered consciousness
• Severe hypertension with headache
• Headache refractory to initial therapy
• Non-positional headache after suspected PDPH

Moderate-risk features 2, 7:

• Fever with meningismus
• Headache onset >5 days post-procedure
• Progressive worsening despite treatment

Low-risk features 4, 7:

• Typical migraine pattern with prior history
• Positional headache within 5 days of dural puncture
• Normal blood pressure and neurological exam

Step 3: Imaging Selection

• CT head without contrast: First-line for acute assessment of hemorrhage, mass effect 4.
• MRI/MRV: Superior for detecting CVST, posterior reversible encephalopathy syndrome, ischemia 6.
• CT venography: Alternative when MRI unavailable for suspected CVST 6.

Common Diagnostic Pitfalls

• Discharging patients with simple analgesics without excluding secondary causes 1.
• Missing preeclampsia in women with new-onset headache and hypertension 1.
• Attributing all post-epidural headaches to PDPH without considering CVST, which can initially present with positional features 5.
• Delaying imaging in patients with atypical features or treatment failure—68% of imaged patients in one series had abnormal findings 4.
• Assuming benign etiology based solely on normal initial examination—serious pathology can evolve over days 5, 6.

Peripartum Cardiomyopathy Consideration

While primarily a cardiac diagnosis, peripartum cardiomyopathy can present with symptoms that may include headache as part of heart failure syndrome 3. Consider cardiac evaluation with BNP and echocardiography if dyspnea, orthopnea, or other heart failure symptoms accompany headache 3.