Headache in the postpartum woman: horses or zebras?
Irwin K¹, Clark E^1
1Women’s and Children’s Hospital, North Adelaide, SA, Australia

Background: Headache in the postpartum woman is a common complaint; fortunately the majority have a benign cause ^(1-2).  The infrequency of serious underlying pathology may delay necessary investigations, however identification of a sinister cause is essential to ensure optimal outcomes for women.

Aims:  To highlight ‘red flags’ in the presentation of postpartum headache which warrant further investigation. 

Methods:  A series of three patients presenting with headache in the postpartum period is described.  Each patient was found to have an uncommon cause (a so-called ‘zebra’); the reported cases include vertebral artery dissection, intra-cranial haemorrhage and postpartum angiopathy.  A review of the literature pertaining to each of the three diagnoses was performed.

Results: Each patient presented with severe headaches, and with specific features which ultimately triggered radiological investigation and diagnosis.   Confounding issues (e.g. concomittent hypertension) and unfamiliarity with the pathologies contributed to delays in imaging and diagnosis; this was also an issue highlighted in the literature. 

Conclusions:  Women with headache in the postpartum period in the presence of neurological deficits require thorough neurological examination with the use of imaging.  Any new persistent or recurring headache without adequate response to simple therapies should also be investigated for a more sinister cause.