What is Postpartum Headache?
Headaches are a common complaint in emergency departments, especially among women of childbearing age. The frequency of headaches increases after childbirth due to the drastic changes – both chemical and social – that occur during the post-birth period. There’s a tendency for data and studies on post-birth headaches to focus on severe headaches because many people with mild or moderate headaches choose to handle their pain with over-the-counter medicine rather than seek medical help.
This could make it challenging to distinguish between different conditions that cause headaches after childbirth since many of them share similar features, and it’s possible to have more than one type of headache at the same time. Medical professionals tend to do more advanced tests and scans on this group than others in the same age range. This makes it extremely important for them to take a detailed patient history and do a thorough physical exam, paying close attention to any warning signs or subtle neurological symptoms that might be easy to miss.
What Causes Postpartum Headache?
After childbirth, headaches are commonly caused by an increase in existing conditions such as migraines, cluster headaches, or tension headaches. Headaches associated with an epidural during labor, known as Post-dural puncture headaches (PDPH), are also frequent, with over half of the women who experience undesired puncturing during an epidural reporting headaches afterward.
These types of headaches, including those caused by existing conditions and PDPH, are typically not dangerous in the long term. They form the majority of severe headache cases after childbirth. However, severe life-threatening headaches during the post-birth recovery phase can also occur due to complications from the anesthesia used during delivery, inherent brain conditions, or complications related to childbirth.
Identifying the causes for such severe headaches after childbirth can be challenging. This is because women who are predisposed to primary headaches are also at a higher risk of developing high blood pressure-related issues during pregnancy and severe brain blood vessel issues, both of which can present as headaches after childbirth. Furthermore, post-birth physiological changes and increased prevalence of domestic and intimate partner violence also contribute to the prevalence of severe brain-related conditions.
Dangerous conditions causing headaches in the post-birth period can include brain tumors, high blood pressure following childbirth (preeclampsia), meningitis, strokes, sinus vein clots (sinus venous thrombosis or SVT), and transient narrowing of the blood vessels in the brain, commonly referred to as Call-Fleming syndrome or postpartum cerebral angiopathy.
Risk Factors and Frequency for Postpartum Headache
Headaches are experienced by about 40% of women after giving birth. They are more frequently seen in women who have had headaches before, are older, have given birth more than once, or had a shorter second stage of labor.
Signs and Symptoms of Postpartum Headache
When a woman has a headache after giving birth, doctors need to determine whether it’s a normal side effect of childbirth or a sign of a more serious problem. Here are some key details doctors look for:
- When the baby was born
- Whether the birth was vaginal or surgical
- Any pregnancy complications like pre-eclampsia or gestational hypertension
- Complications during the delivery, like excessive bleeding or fevers after giving birth
- Use of epidural anesthesia during delivery
- Any new medications the mother is taking
- Use of illegal drugs
- Whether the mother or her family have a history of blood clotting or bleeding disorders
- Shortness of breath
- Chest pain
- Sudden, severe onset of headache, often described as a “thunderclap”
During a physical examination, doctors also look for certain symptoms that might suggest the headache is due to a more serious condition:
- High blood pressure
- Decreased urination
- Swelling in the lower legs
- Changes in vision
- Abnormal findings during a neurological examination, like overly active reflexes
Testing for Postpartum Headache
Diagnosing primary headache disorders and post-dural puncture headaches usually involves a simple clinical assessment; no extra lab tests or imaging are needed. However, if a secondary headache disorder is suspected after childbirth, medical professionals may carry out several checks. These could include analyzing the urine, calculating protein to creatinine ratio in a urine sample, complete blood count, and a comprehensive metabolic panel. They might also test for lactate dehydrogenase, which is an enzyme found throughout the body.
If there’s a suspicion of meningitis, a lumbar puncture (also known as a spinal tap) might be done to examine the spinal fluid. The type of imaging used depends on what condition is suspected. A non-contrasted head CT scan, which is quick and non-invasive, is suitable for detecting spontaneous and traumatic brain bleeding but it’s not very good at spotting early signs of stroke or sinus vein clotting.
For sinus vein clotting, CT venography, which uses a CT scan to check the veins, is as good as MR venography and is more commonly available. An MRI scan is usually the best option for detecting early signs of stroke because it can provide a clearer image of the soft tissues, such as the brain and spinal cord.
Treatment Options for Postpartum Headache
How post-birth headaches are managed depends on what’s causing the headache. For primary headaches, treatment generally involves pain relief and advice on the need for regular nutrition and sleep. The go-to treatment for headaches after childbirth is bed rest, painkillers, hydration through an IV and caffeine supplements. If patients don’t respond to these treatments within 48 hours, a “blood patch” procedure may be needed.
Headaches in new mothers caused by other underlying issues often need to be addressed with the help of different medical specialists. They would focus both on immediate treatment and long-term prevention. If preeclampsia (high blood pressure during pregnancy) is causing the headache, it can usually be resolved with treatment like magnesium and blood pressure-lowering medications, under close monitoring by pregnancy care services.
When it comes to strokes, it should ideally be managed with the help of a neurologist to decide if clot-dissolving medications or a special surgical procedure to remove the clot is needed. Brain bleeds, either spontaneous or injury-induced, might call for a surgical operation by a neurosurgeon. Treatment for blood clot in a brain sinus, a condition known as sinus venous thrombosis, typically involves using blood-thinning medications.
What else can Postpartum Headache be?
When a doctor is trying to diagnose a health problem related to the brain, there are several conditions they might need to consider. These can include:
- A stroke, also known as a cerebral infarction
- Cortical vein thrombosis, a blood clot in the brain
- Meningitis, an infection of the protective coverings of the brain and spinal chord
- Migraines, which are severe headaches
- Tension headaches, which are often caused by stress
- Post-dural puncture headaches, which can happen after certain medical procedures
- Pre-eclampsia, a condition that can happen during pregnancy
- Sinusitis, an inflammation or swelling of the sinuses
- Brain tumors, which are masses of cells in the brain that grow in a way that the body can’t control
- Subarachnoid haemorrhage, a type of stroke caused by bleeding on the surface of the brain
In order to find out which condition is causing the problem, the doctor may need to conduct several tests.
What to expect with Postpartum Headache
Exacerbations of primary headache disorders and post-dural puncture headaches (PDPH) have excellent outcomes as neither is life-threatening. Despite this, they can still result in delayed recovery, financial hardship, and additional emotional distress during already tense periods in life. Doctors should factor these complications into their patient advisories, home care instructions, and follow-up care plans. The prognosis for other types of secondary headaches depends on the underlying condition.
Patients with postpartum complications due to preeclampsia have a mortality rate of 6.4 per 10,000 cases. Studies have found that African American women face a higher risk than the general population for developing postpartum preeclampsia, which can escalate to eclampsia, leading to higher rates of sickness and death from blood pressure-related conditions during pregnancy and childbirth.
Meningitis during the postpartum period carries about a 20% mortality rate, mostly because of a delay in diagnosis rather than substantial antibiotic resistance in these patients. Strokes during the postpartum period have a 5% mortality rate, with bleeding strokes posing a bigger risk than blood clot-causing strokes, and can lead to significant, permanent functional decline.
Patients with blood pressure disorders during pregnancy have a higher chance of complications, which could necessitate breathing assistance and a prolonged hospital stay.
Possible Complications When Diagnosed with Postpartum Headache
It’s very important to quickly identify and start treatment for secondary headache syndromes. If this doesn’t happen in a timely manner, there could be serious consequences, like death or lifelong disability. These syndromes are especially serious in younger people, as an immediate treatment can significantly increase their quantity and quality of life. Failing to diagnose or treat these conditions on time can also lead to social and legal issues.
Preventing Postpartum Headache
The most common reason for headaches after childbirth is usually an increase in underlying headache conditions. Therefore, teaching patients about modifying risk factors and the correct use of non-prescription painkillers can help reduce return visits to the emergency room. A clear discussion about safe medications to use after childbirth, especially for breastfeeding mothers, may help reduce worry about self-medicating.
Doctors should provide thorough and detailed instructions to patients who come to the emergency room with headaches after childbirth and are then discharged. These instructions are essential to avoid further delays in diagnosing potentially more serious conditions that may have been overlooked initially.
