Unusual Case of Labor-Induced Occipital Neuralgia, Mimicking Post-Dural Puncture Headache
Abstract Number: S-63
Abstract Type: Case Report/Case Series
Although post partum headache is relatively common and has a multitude of possible causes including inadvertent dural puncture, we are presenting an unusual case of labor-induced occipital neuralgia, mimicking post dural puncture headache and other more serious conditions (Klein and Loder, 2010).
Patient is a 38 year old woman, G2P1A1, who initially presented with spontaneous rupture of membranes at 38 weeks gestation. She received an epidural from anesthesia for labor analgesia and had an uncomplicated spontaneous vaginal delivery. There was no indication of inadvertent dural puncture while performing the epidural. The rest of her hospital stay was unremarkable and she was discharged home on the second post partum day.
The patient returned to the labor and delivery unit on the 6th post partum day complaining of severe neck pain for 3-4 days that had progressively worsened. She reported that the pain radiated from the neck to the crown of her head and was partially relieved by lying down. She was admitted for evaluation by anesthesia for a possible post dural puncture headache and autologous epidural blood patch. On examination, we ascertained that the headache was not really relieved by the recumbent position, rather it was exacerbated by flexion of her neck both while lying down or standing up. We felt that the cause of her headache was not a dural puncture and that an epidural blood patch would not be of any benefit. We also decided that the best course was to consult a neurologist to better evaluate the patient.
The neurologist concurred with our impression that it was not a post dural puncture headache. As part of the neurologic evaluation, the patient had radiographs of her cervical spine, duplex scans of the neck vasculature, CT scan of the brain, MRI of the brain, MRA of the circle of Willis and MR venogram of the intracranial venous sinuses. All of these studies were unremarkable. The neurologist suspected that the cause of the headache was occipital neuralgia triggered by bearing down and neck straining during labor. The patient was started on prednisone to treat the occipital neuralgia and was given oxycodone-acetaminophen for pain relief. Her symptoms improved rapidly after starting the steroid and she was discharged home the next day with instructions to follow up with the neurologist as an out-patient. At the follow-up visit she did not have any neck pain and the steroid was tapered off.
It is often assumed that a patient has a post dural puncture headache when she presents with neck pain or headache in the first few days after a labor epidural. When the presentation is atypical, as was the case with our patient, it would be wise to look for other less common causes. This may allow the patient to get the right therapy and quicker relief from her symptoms as well as protect her from unnecessary invasive procedures.
Klein, AM and Loder, E (2010). "Postpartum headache." Int J Obstet Anesth 19(4):422-430.