Case study - Postnatal headaches

Dr Keith Thomson on the treatment of postnatal headaches

Postnatal headache can be attributed to multiple attempts at an epidural during birth (Photograph: SPL)
Postnatal headache can be attributed to multiple attempts at an epidural during birth (Photograph: SPL)

Mrs C, a friend of mine who lives in Australia, had an elective caesarean section under regional anaesthesia for the delivery of her second baby.

Apparently her anaesthetist tried and failed several times to insert an epidural so eventually resorted to a spinal block.

During the surgery, Mrs C developed a severe headache for which she was given strong painkillers postoperatively.

She was sent home on day four but her frontal headache and photophobia persisted.

She reported that her symptoms were better when she lay down but worse when she sat or stood up. This made it difficult to care for her new baby.

Her GP prescribed cefalexin and codalgin forte which made no difference to her headache.

After she contacted me to say she was returning to her GP for more investigations, I emailed her the following letter to give to her doctor:

'Mrs C underwent an elective caesarean section on 13 January under regional anaesthesia. The anaesthetist apparently had difficulty performing an epidural so they then did a spinal block.

'If you have multiple attempts at an epidural there is an increased risk of dural puncture leading to a postdural puncture headache (PDPH), which I suggest may be the cause of the headache.

'PDPH can occur even though the anaesthetist may not have seen any CSF during the procedure.

'The main features are that the headache is postural. The headache may be frontal, occipital or both and can be associated with neck stiffness and photophobia. The rare complications of sixth nerve palsy and even fits have been described in association with PDPH.

Best treatment
'If you feel she might have a PDPH then she should be referred back to a consultant obstetric anaesthetist at the hospital where her baby was born. The best treatment is epidural blood patch with 15-20ml of her own blood.'

Her GP referred her back to the hospital and her headache was cured by a blood patch performed over two weeks after delivery.

In the UK the incidence of PDPH is said to be one in 100 after epidurals and one in 500 after spinal blocks.

It is important that after regional anaesthesia for obstetric procedures, patients should be seen on the postnatal ward by an anaesthetist prior to discharge and that GPs should be more aware of a possible diagnosis of PDPH.

  • Dr Thomson is a consultant anaesthetist, Basingstoke and North Hampshire hospitals

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