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Management of Postpartum Headache: Thinking Outside the Box
Abstract Number: SU-21
Abstract Type: Case Report/Case Series
Intro: Headache is common in the postpartum period. There are many reasons for headache following delivery, and differential diagnoses should include both anesthesia and non-anesthesia related etiologies. Thoughtful work-up is necessary to provide patients with proper treatment.
Case report: The patient is a 44 year-old G3P0 with a mono-di twin pregnancy at 33 weeks’ gestation who presented for cesarean section (C/S) due to elevated dopplers in Twin B. Her history was notable for Factor V Leiden deficiency, without prior venous thromboembolic events. The patient was not receiving anticoagulation. She underwent an uncomplicated C/S under single-shot spinal anesthesia and was discharged to home on postpartum day (PPD) #2. On PPD#8, the patient returned to the hospital with a chief complaint of headache located in the frontal and parietal regions that she reported began on PPD#2. The headache was initially intermittent, but became continuous in nature. There was no associated fever, nausea, photophobia, or other neurologic symptoms. Both oxycodone and ibuprofen failed to provide significant relief. Anesthesiology was consulted for an epidural blood patch. However, the likelihood of postdural puncture headache (PDPH) was thought to be low given that the headache lacked a postural component and that spinal anesthesia had been performed with a single pass of a 27G Whitacre needle. Magnetic resonance imaging (MRI) of the brain showed no evidence of hemorrhage, intracranial mass, cerebral venous sinus thrombosis, intracranial hypotension, or dural enhancement. However, it did reveal a possible right cervical internal carotid artery (ICA) dissection, which was further evaluated with magnetic resonance angiography (MRA) of the head and neck. MRA revealed severe focal narrowing of the right cervical ICA lumen approximately 3.5 cm above the bifurcation with an intramural hematoma secondary to dissection. The patient was immediately started on low molecular weight heparin and warfarin. She was discharged to home on PPD#11 with neurology follow-up in place. Repeat MRA 3 months later demonstrated interval improvement in the right cervical ICA with normal vessel caliber above and below the dissection.
Discussion: Although rare among postpartum patients, carotid artery dissection should be considered in the differential diagnosis of postpartum headache. The typical presentation is ipsilateral head, neck, facial, or ophthalmic pain. Horner’s syndrome and/or ischemic cerebral events can also occur. Diagnosis hinges on a complete neurologic examination and non-invasive neuroimaging. Physiologic changes of pregnancy are one proposed mechanism that may predispose women to spontaneous dissection. Treatment is centered on anticoagulation to prevent thrombus formation and propagation.
1. Kelly JC, et al. Obstet Gynecol. 2014 Apr;123(4):848-56.