Postpartum Headache: A Prospective Study

Aims: To prospectively assess the incidence and etiology (ie, primary vs symptomatic) of headache in women during the first month postdelivery, with particular emphasis on the type of presentation as a clue for identifying potentially harmful etiologies. A secondary aim was to evaluate the relative frequency of migraine- vs tension-type headache in cases of primary headache. Methods: A total of 900 consecutive women were enrolled in the study and examined within 3 days of delivery, both clinically and with transcranial color-coded sonography (TCCS). During the course of follow-up, all subjects presenting with headache suspected of being secondary to intracranial pathology underwent a complete clinical and instrumental assessment with TCCS and magnetic resonance imaging (MRI) and angiography. A telephone interview was administered to all subjects 1 month after delivery. Two-tailed t test, Mann-Whitney test, Pearson chi-square test, and multiple logistic regression were used to analyze the data. Results: At the end of the follow-up period, 241 women (26.8% of the sample) reported at least one headache attack. In 88 of these 241 cases (9.8%), the headache attack occurred soon after delivery and was already recorded at the first visit. Thunderclap headache occurred in 34 (3.8%) of the subjects. In all but one of these subjects, the course was spontaneously benign. None of the recorded variables allowed discrimination of the subjects with thunderclap headache from those without headache. Three subjects had thunderclap headache following dural anesthesia, and one subject was found to have reversible cerebral vasoconstriction syndrome. Headache with gradual onset was recorded in 207 subjects (23%). Three of these subjects fulfilled the criteria for pre-eclampsia, and 13 had postural headache after dural anesthesia. Migraine history and urinary protein were independent predictors of gradual onset headache, and migraine history and parity were significant independent predictors of pulsating pain with gradual onset headache. Conclusion: Headache appeared early in the first days postdelivery, and its incidence increased in the first month thereafter. Predictors were different according to whether the headache had a gradual onset or a thunderclap presentation. Primary headache accounted for the overwhelming majority of the recorded cases.

migraine; puerperium; reversible cerebral vasoconstriction syndrome; thunderclap headache

1. Del Zotto E, Giossi A, Volonghi I, Costa P, Padovani A, Pezzini

A. Ischemic stroke during pregnancy and puerperium. Stroke Res Treat 2011;2011:606780.

2. Cantu-Brito C, Arauz A, Aburto Y, Barinagarrementeria F, Ruiz-Sandoval JL, Baizabal-Carvallo JF. Cerebrovascular complications during pregnancy and postpartum: Clinical and prognosis observations in 240 Hispanic women. Eur J Neurol 2011; 18:819–825.

3. Khan M, Wasay M. Haemorrhagic strokes in pregnancy and puerperium. Int J Stroke 2013;8:265–272.

4. Schebesch KM, Schödel P, Rennert J, Mark KH, Brawanski

A. Subarachnoid hemorrhage from posterior cerebral artery aneurysm during puerperium—Case report and review of literature. J Neurol Neurophysiol 2012;3:1–3.

5. Seo P. Pregnancy and vasculitis. Rheum Dis Clin North Am 2007;33:299–317.

6. Lim SY, Evangelou N, Jürgens S. Postpartum headache: Diagnostic considerations. Pract Neurol 2014;14:92–99.

7. Goldszmidt E, Kern R, Chaput A, Macarthur A. The incidence and etiology of postpartum headaches: A prospective cohort study. Can J Anaesth 2005;52:971–977.

8. Stella CL, Jodicke CD, How HY, Harkness UF, Sibai BM. Postpartum headache: Is your work-up complete? Am J Obstet Gynecol 2007;196:318.e1–e7.

9. Scharff L, Marcus DA, Turk DC. Headache during pregnancy and in the postpartum: A prospective study. Headache 1997; 37:203–210.

10. Hoshiyama E, Tatsumoto M, Iwanami H, et al. Postpartum migraines: A long-term prospective study. Intern Med 2012;51: 3119–3123.

11. Kvisvik EV, Stovner LJ, Helde G, Bovim G, Linde M. Headache and migraine during pregnancy and puerperium: The MIGRA-study. J Headache Pain 2011;12:443–451.

12. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013;33:629–808.

13. Ducros A, Boukobza M, Porcher R, Sarov M, Valade D, Bousser MG. The clinical and radiological spectrum of reversible cerebral vasoconstriction syndrome: A prospective series of 67 patients. Brain 2007;130:3091–3101.

14. Calabrese LH, Dodick DW, Schwedt TJ, Singhal AB. Narrative review: Reversible cerebral vasocontriction syndromes. Ann Intern Med 2007;146:34–44.

15. Singhal AB, Hajj-Ali RA, Topcuoglu MA, et al. Reversible cerebral vasoconstriction syndromes: Analysis of 139 cases. Arch Neurol 2011;68:1005–1012.

16. Ducros A. Reversible cerebral vasoconstriction syndrome. Lancet Neurol 2012;11:906–917.

17. Skeik N, Porten BR, Kadkhodayan Y, McDonald W, Lahham F. Postpartum reversible cerebral vasoconstriction syndrome: Review and analysis of the current data. Vasc Med 2015;20: 256–265.

18. Schwedt TJ, Matharu MS, Dodick DW. Thundereclap headache. Lancet Neurol 2006;5:621–631.

19. Anzola GP, Brighenti R, Cobelli M, et al. Reversible cerebral vasoconstriction syndrome in puerperium: A prospective study.J Neurol Sci 2017;375:130–136.

20. Bartels E. Color-Coded Duplex Ultrasonography of the Cerebral Vessels: Atlas and Manual. Stuttgart: Schattauer, 1999.

21. Felberg RA, Christou I, Demchuk AM, Malkoff M, Alexandrov AV. Screening for intracranial stenosis with transcranial Doppler: The accuracy of mean flow velocity thresholds. J Neuroimaging 2002;12:9–14.

22. Lindegaard KF, Nornes H, Bakke SJ, Sorteberg W, Nakstad P. Cerebral vasospasm diagnosis by means of angiography and blood velocity measurements. Acta Neurochir (Wien) 1989; 100:12–24.

23. Stein GS. Headaches in the first post partum week and their relationship to migraine. Headache 1981;21:201–205.

24. Stein G, Morton J, Marsh A, et al. Headaches after childbirth. Acta Neurol Scand 1984;69:74–79.

25. Brass LM, Pavlakis SG, DeVivo D, Piomelli S, Mohr JP. Transcranial Doppler measurements of the middle cerebral artery. Effect of hematocrit. Stroke 1988;19:1466–1469.

26. Krayenbuehl PA, Naumann KU, Käser L, Vetter EW. Iron deficiency anemia in adults. Main symptoms: Fatigue, pallor,(stress-) dyspnea, headache, concentration disorders [in German]. Praxis (Bern 1994) 2007;96:1241–1247.

27. Sibai BM. Diagnosis, prevention, and management of eclampsia. Obstet Gynecol 2005;105:402–410.

28. Cindrova-Davies T. Gabor Than Award Lecture 2008: Pre-eclampsia—From placental oxidative stress to maternal endothelial dysfunction. Placenta 2009;30(suppl):s55–s65.

29. Schwedt TJ. Endothelial dysfunction in migraine. Cephalalgia 2009;29:997–1002.

30. Butt JH, Franzmann U, Kruuse C. Endothelial function in migraine with aura—A systematic review. Headache 2015;55:35–54.

31. Simbar M, Karimian Z, Afrakhteh M, Akbarzadeh A, Kouchaki

E. Increased risk of pre-eclampsia (PE) among women with the history of migraine. Clin Exp Hypertens 2010;32:159–165.

32. Methylergonometrine. Drugbank. https://www.drugbank.ca/drugs/DB00353. Accessed 31 August 2017.

33. Sabharwal A, Stocks GM. Postpartum headache: Diagnosis and management. Contin Educ Anaesth Crit Care Pain 2011;11: 181–185.

34. Chen SP, Fuh JL, Chang FC, Lirng JF, Shia BC, Wang SJ. Transcranial color Doppler study for reversible cerebral vasoconstriction syndromes. Ann Neurol 2008;63:751–757.

35. Anzola GP, Brighenti R, Cobelli M, et al. Cerebral haemodynamics in early puerperium: A prospective study. Ultrasound 2017;25:107–114.

36. Miller TR, Shivashankar R, Mossa-Basha M, Gandhi D. Reversible cerebral vasoconstriction syndrome, part 2: Diagnostic work-up, imaging evaluation, and differential diagnosis. AJNR Am J Neuroradiol 2015;36:1580–1588.