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Year : 2011  |  Volume : 1  |  Issue : 2  |  Page : 55-56

Postpartum headache: Mandates correct clinical diagnosis and right intervention

Department of Anaesthesia, Pain and Critical Care, Prerna Anaesthesia and Critical Care Services, Fernandez Hospital, Hyderabad, India

Date of Web Publication17-Mar-2012

Correspondence Address:
Sunil T Pandya
12-13-627/1, 1217, Nagarjuna Nagar, Tarnaka, St. No. 14, Secunderabad - 500 017
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2249-4472.93987

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How to cite this article:
Pandya ST. Postpartum headache: Mandates correct clinical diagnosis and right intervention. J Obstet Anaesth Crit Care 2011;1:55-6

How to cite this URL:
Pandya ST. Postpartum headache: Mandates correct clinical diagnosis and right intervention. J Obstet Anaesth Crit Care [serial online] 2011 [cited 2022 May 19];1:55-6. Available from: https://www.joacc.com/text.asp?2011/1/2/55/93987

Postpartum headache is one of the commonest morbidity experienced by approximately 38-40% of parturients during the puerperium. [1] Most headaches occur during first week following delivery. The causes of postpartum headache could vary from simple primary causes of headache like tension headache to lactation headache to the more serious secondary causes with intracranial pathologies, which if unattended, can lead to severe morbidity and sometimes mortality. [2],[3],[4]

Intentional dural puncture during subarachnoid blocks and accidental dural puncture during epidural blocks leading to postdural puncture headache (PDPH) is one of the important cause of postpartum headache and often demands highest clinical and interventional skills from the attending anesthesiologist. The seemingly minor complication of PDPH has appeared as a cause of 18% of the closed claims cases in the American Society of Anesthesiologists' Closed Claims Project, [5] hence cannot be ignored.

The safety and revolutionary resurgence of neuraxial anesthesia technique in parturients both for operative deliveries and for labor pain relief has lead to increase in the incidence of postpartum headache. Good obstetric regional anesthetic practice demands restriction of accidental dural puncture rate to be less than 0.8%, however, in training institutes, the incidence varies anywhere between 1 and 5%.

Since the time PDPH was first experienced and reported by August Bier and Heidel Brandt in 1898, more than a century ago, there have been a lot of research to study the risk factors, pathophysiology, treatment options and preventive aspects of PDPH. [4],[6] There is no clear consensus on how best to prevent severe headache from occurring after accidental dural puncture. The review article in this issue addresses these issues in detail.

As a clinician, the onus is on our part to differentiate between less serious primary headaches from more serious secondary headaches, as management options varies. Atypical orthostatic headache demands appropriate investigation and the right treatment is targeted, as certain other uncommon peripartum conditions like venous thrombosis, subdural hematoma mimics PDPH by its orthostatic nature of headache. [4],[6],[7] Spontaneous CSF leak (Shaltenbrand syndrome) unrelated to wet tap can mimic PDPH. [7]

Even though epidural blood patch is considered the gold standard for treating severe PDPH, it is not 100% safe. [8],[9] There is a risk of second dural puncture during EBP; it may cause seizures, [10] blindness, subdural hematoma and rarely can also cause brachial plexopathy. [11] There are a number of other conservative options like prophylactic use of parenteral cosyntropin, [12] newer serotonin receptor antagonists frovatriptan [13] etc., which have expanded the armamentarium for the anesthesiologists in treating PDPH. There are case reports of treating PDPH by nerve stimulator guided occipital nerve block. [14] However the heterogeneity of various studies and small observational studies limit the available evidence. Intrathecal catheterization after an accidental dural puncture has also generated lot of interest as, it lowers the incidence for the need of EBP by almost 40%. [15]

PDPH is one of the important causes of postpartum headache and warrants right diagnosis and appropriate intervention as it can hamper the joy of giving birth to a child and also has medico legal implications. Risk reduction strategies in terms of going up the learning curve for obstetric epidurals and using only pencil-point needles for subarachnoid blocks, regular clinical audit cannot be over emphasized. [16],[17]

  References Top

1.Goldszmidt E, Kern R, Chaput A, Macarthur A. The incidence and etiology of postpartum headaches: A prospective cohort study. Can J Anesth 2005;52:971-7.  Back to cited text no. 1
2.Benhamou D, Hamza J, Ducot B. Postpartum headache after epidural analgesia without dural puncture. International J Obstet Anesth 1995; 4:17-20.  Back to cited text no. 2
3.Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders: 2 nd edition. Cephalagia 2004;24 Suppl 1:S8-152.  Back to cited text no. 3
4.Bezov D, Lipton RB, Ashina S. Post-dural puncture headache: Part I diagnosis, epidemiology, etiology, and pathophysiology. Headache 2010;50:1144-52.  Back to cited text no. 4
5.Chadwick HS. An analysis of obstetric anesthesia cases from the American Society of Anesthesiologists' closed claims project database. Int J Obstetric Anesth 1996;5:258-63.  Back to cited text no. 5
6.Stella CL, Jodicke CC, How HY, Harness UF, Sibai BM. Postpartum headache: Is your work-up complete? Am J Obstetric Gynecology 2007;196:318.e1-e7.   Back to cited text no. 6
7.Ferrante E, Wetzl R, Savino A, Citterio A, Protti A. Spontaneous cerebrospinal fluid leak syndrome: Report of 18 cases. Neurol Sci 2004;25 Suppl 3:S293-5.  Back to cited text no. 7
8.Boonmak P, Boonmak S. Epidural blood patching for preventing and treating post-dural puncture headache. Cochrane Database Syst Rev 2010;(1):CD001791.  Back to cited text no. 8
9.Barrington MJ, Snyder GL. Neurologic complications of regional anesthesia. Curr Opin Anaesthesiol 2011;24:554-60.  Back to cited text no. 9
10.Kardash K, Morrow F, Béïque F. Seizures after epidural blood patch with undiagnosed subdural hematoma. Reg Anesth Pain Med 2002;27:433-6.  Back to cited text no. 10
11.Shahien R, Bowirrat A. Facial nerve paralysis and partial brachial plexopathy after epidural blood patch: A case report and review of the literature. J Pain Res 2011:4:39-45.  Back to cited text no. 11
12.Hakim SM. Cosyntropin for prophylaxis against post dural puncture headache after accidental dural puncture. Anaesthesiology 2010;113:413-20.  Back to cited text no. 12
13.Bussone G, Tullo V, d'Onofrio F, Petretta V, Curone M, Frediani F, et al. Frovatriptan for the prevention of postdural puncture headache. Cephalalgia 2007;27:809-13.  Back to cited text no. 13
14.Naja Z, Al-Tannir M, El-Rajab M, Ziade F, Baraka A. Nerve stimulator-guided occipital nerve blockade for postdural puncture headache. Pain Pract 2009;9:51-8.  Back to cited text no. 14
15.Dennehy KC, Rosaeg OP. Intrathecal catheter insertion during labour reduces the risk of post-dural puncture headache. Can J Anaesth 1998;45:42-5.  Back to cited text no. 15
16.Apfel CC, Saxena A, Cakmakkaya OS, Gaiser R, George E, Radke O. Prevention of postdural puncture headache after accidental dural puncture: A quantitative systematic review. Br J Anaesth 2010;105:255-63.  Back to cited text no. 16
17.Bezov D, Ashina S, Lipton R. Post-Dural Puncture Headache: Part II Prevention, Management, and Prognosis. Headache 2010;50:1482-98.  Back to cited text no. 17


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