Objective

To describe acute headache diagnoses in women presenting emergently in the postpartum period and to determine which factors may be associated with secondary vs primary headache.

Background

Hormonal, vascular, and procedural factors elevate the risk for both secondary and primary headache disorders in the postpartum period. Differentiating between these can be a diagnostic challenge, particularly among the most severe patients referred for urgent neurological consultation.

Methods

A single-center retrospective study of consecutive postpartum women age ≥18 years presenting with acute headache to a large urban tertiary-care hospital and receiving neurological consultation.

Results

Of 63 women who presented with acute postpartum headache, 17 (27.0%) were diagnosed with a primary headache disorder and 46 (73.0%) were diagnosed with a secondary headache disorder. Migraine comprised the majority of primary headache diagnoses (76.5%). Secondary headache most commonly featured postdural puncture headache (PDPH) (45.7%), postpartum preeclampsia (PEC) (26.1%), and a diverse group of cerebrovascular headache disorders (21.7%). Presentation within 24 hours and lack of side predominance helped to differentiate PDPH from migraine. However, abnormal diagnostic testing was more prevalent in the patients with headache secondary to cerebrovascular disorders/PEC.

Conclusions

Nearly three-quarters of postpartum women who present with acute onset headache and receiving neurological consultation are found to have a secondary headache – with nearly half of the secondary headaches attributed to PEC or cerebrovascular headache disorders. The absence of a headache history and a clear PDPH description should prompt strong consideration for neuroimaging to rule out cerebrovascular etiologies of headache as well as close monitoring for signs and symptoms of preeclampsia in women presenting with acute severe postpartum headache.

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