Haven’t we all experienced the common blame game in OB? Patient may not even have an epidural but the nurse would still call you to evaluate thinking automatically the post-dural puncture headache. If patients have epidural placed, the assumption of PDPH is even higher. However, we the OB anesthesia providers know the headache of an OB patient is not always the result of post-dural puncture.
Interestingly, the degree of CSF leak or CSF volume does not predict headache. In 5 patients who developed PDPH after lumbar puncture, MRI showed the CSF leak was small in 2 (<10ml), moderate in 1 (10-110) and large in another (110ml). The 5th patient had CSF leak for 7 days but never developed headache.
- Incomplete correlation HA and CSF leak
- Incomplete correlation HA and intracranial CSF
- Wet tap does not mean that patient will develop headache, and even after wet tap, not all headaches are PDPH!
Headache 1995; 35: 420
A 5 year obstetric review of postpartum headache persisting> 24 hours reaches 4 conclusions:
1.Tension and migraine HA are the most common diagnosis.
2.Late onset severe preeclampsia should be ruled out.
3.Cerebral imaging is indicated for any neurologic deficit or failure to improve with treatment of presumed diagnosis.
4.Consultation with neurologist is indicated (if neuro deficits are present)
In particular, retrospective review of delayed postpartum preeclampsia:
- 63% had not been diagnosed with preeclampsia during their delivery.
- 14.5% developed eclampsia, all in the first week.
- Most common presentation was headache in 69%.
- Other risk factors were young age and anemia.
Obstet Gynecol 2011; 118: 1102
Sometimes, other disease process may cause headache which may manifest in a similar fashion as PDPH as shown in the case studies below:
Case report #1 of a missed diagnosis:
- Day 0: healthy G1 in active labor had an accidental dural puncture
- Day 2: postural HA successful blood patch home
- Day 3: postural HA recurred successful patch home
- Day 5: HA recurred but not postural so treated for migraine by neurologist
- Day 6: Grand mal seizures x 4, confusion, sedation
- Day 7: MRI cortical vein thrombosis
Br J Aneaesth 2000; 84: 407
Case report #2
- 27 year old parturient developed a headache within 12 hours of delivery and subsequently seized. Further examination, including MRI and CT scan, showed partial thrombosis of a transverse venous sinus. She was found to have an activated protein C resistance caused by a heterozygote factor V Leiden mutation and heterozygote prothrombin-gene mutation G20210A. Seven months after delivery, the patient is in good health, showing no neuro-cognitive disability.
J Clin Anesth 2007; 19: 549
Case report #3
- A 30 year old G1 had an unintentional dural puncture during attempted epidural placement, followed by GETA for cesarean. She received routine thrombo-prophylaxis after surgery. The next day she complained of severe HA that did not respond to fluids or caffeine. A blood patch was performed uneventfully. 1-2 hours later she developed hemiparesis and CT scan showed an intracerebral hematoma.
Case report #4: preeclampsia
- Two days after uneventful spinal for cesarean the patient developed severe postural headache. After 4 days of conservative therapy (analgesics, hydration, bedrest), the headache was 10/10 and no longer postural. She became somnolent and confused with visual hallucinations, had right-sided facial and limb numbness, and slurred speech. Normal CT and MRV. MRA showed diffuse vasospasm that completely reversed with magnesium therapy.
Anesth Analg 2007; 105: 770.
Case report #5: subdural hematomas
- inadvertent dural puncture during epidural placed was followed by a positional PDPH. Blood patch provided only partial relief. Headache gradually became non-positional and associated with pain and paresthesias in her lower extremities. CT showed bilateral subdural hematomas, managed conservatively with daily CT scans.
Can J Anesth 2012; 59: 389
Our common differential diagnoses:
- Migraine (history?)
- Cervical myofascial pain after prolonged pushing
- Pneumocephalus (loss of resistance to air?)
- CNS infection
- Caffeine withdrawal
- Cortical vein thrombosis (associated with dehydration, preeclampsia, throbophilia)
- CNS hemorrhage
Differential for Thrombosis:
- Reasons to consider intracranial thrombosis in a parturient:
1.Consider in your differential of postpartum HA, especially if there are risk factors for thrombosis.
2.May present with a positional headache, but the nature of the HA often changes over time.
3.EBP does not provide relief.
4.A brief neurologic exam should be performed before EBP. Focal deficits and mental status changes should lead to a neurology consult and imaging.
Anesthesiology 2007; 107: 652.
As we can see, we need to consider our differential diagnoses. Put on your detective cap and pull out your magnifying glasses.