headaches, headaches and more headaches. diagnostic ... nov 1630 stocks…dural venous sinus...

Headaches, headaches and more headaches! Diagnostic dilemmas; looking beyond

PDPH

Dr Gary Stocks

Queen Charlotte’s & Chelsea Hospital Imperial College Healthcare NHS Trust

OAA 3 day course Nov 2012

Case report

• Primip 20 yr old

• One migraine in past

• Requesting epidural

Case report

• Dural Puncture

Case report

• Primip 20 yr old

• One migraine in past

• Requesting epidural

• Dural Puncture

• Epidural resited

• SVD

Day 2 postpartum

• Headache occurs

– Postural

– Occipital

– Neck pain

• Diagnosis: PDPH

Day 2 postpartum

• Headache occurs

– Postural

– Occipital

– Neck pain

• Diagnosis: PDPH

• Treatment:

– Epidural blood patch

• Discharged home

Vakharia et al A&A 1997

Day 3 postpartum

Headache returns!

Now what?

Differential Diagnosis

Klein & Loder IJOA 2010

Incidence

• Goldszmidt, Can J Anaesth 2005

– 985 women 39% headache

– Tension/migraine 20x > PDPH

– 4% debilitating

– Risk factors

• Dural puncture

• Previous headache history

• Multiparity

• maternal age

Primary headache

Tension Migraine

Cluster headache

Migraine

• Precipitated post natally – Falling oestrogen levels

– Sleep disturbance

– Emotional stress

Migraine




• Symptoms – International Classification for Headache Disorders

– Severe, throbbing

– Often unilateral

– Nausea, vomiting, photophobia

Migraine




• Symptoms – International Classification for Headache Disorders

– Severe, throbbing

– Often unilateral

– Nausea, vomiting, photophobia

• Relieved by – Rest

– Sumatripan

– Ergotamine

Primary Headaches

Key points to remember

Migraine flares up after delivery

Migraine is associated with secondary causes

New primary headache is a concern

Low threshold for further evaluation

Back to the case report

• Headache returns

• Failed EBP

• Not Primary headache

• ?

Pre-eclampsia

• BP

• Proteinuria

• Visual disturbances

• reflexes

• urate

• liver enzymes/coagulopathy

Postpartum:

• Readmitted to hospital

• 2nd epidural blood patch: 20ml

• Successfully resolved all symptoms

• Discharged home

Returns again!

• Persistent occipital headache

• Intermittent / throbbing

• Non-postural

• Increasing sedation/confusion

Postpartum

Red flag headache features

• New neurology

• Change in character

• New headache-unilateral

• Vomiting

• Change in mental status

• Unrelieved by analgesics

Secondary causes: Differential diagnosis

Meningitis: 1:10000 - 1:50000

• Fever

• Nausea & vomiting

• Neck stiffness

• WCC

• CSF glucose

• LP > microorganisms

Meningitis: prevention

Differential Diagnosis

Klein & Loder IJOA 2010

Postpartum stroke

• Incidence

– 4.3-210/100 000

– 3rd trimester/postpartum

• Aetiology

– Hypercoaguability

– ↑ oestrogen→vasodilation

and vessel rupture

Classification of stroke

1. Ischaemic emboli

2. Venous sinus thrombosis

3. Pre-eclampsia/eclampsia

Only 10% stroke patients get headache

Ischaemic

Haemorrhagic

Thrombotic

Dural venous sinus thrombosis

• A common cause of stroke in pregnancy

• 1 in 10 000 deliveries

• 1-2 weeks post partum

• Headache, papilloedema, seizure, coma

• Thrombotic tendancy

• MRI/MR venography

Borum ’97: Attempted epidural > ADP > PDPH > EBP x 3 > DVST

Subarachnoid haemorrhage

• 2 in 100,000 deliveries

• Intracranial aneurysms,

BP, AVM

• Atypical headache:

– Sudden / severe onset

– Non-postural

• CT scan

Eggert & Eggers, ’01: spinal for MROP > SAH

Subdural haematoma

• Acute / chronic onset

• Headache

• Seizures

• Coma

• Psychiatric symptoms

• CT scan

Vaughan ’00: ADP > PDPH > x 2 epileptic fits on Day 3 > SDH

Reversible cerebral vasoconstriction syndrome (RCVS)

• Described in 2007

• Severe headache ± neurology

• Cerebral artery constriction

• Resolves 1-3 months

RCVS pathophysiology

• All ages

• Females>males

• ? Disturbed cerebrovascular tone

• “bead & string” angiogram

RCVS aetiology

• Idiopathic but 25-60% are exposed to vasoactive substances or postpartum

• In postpartum 50-70% have had vasoconstrictors for PPH

RCVS Thunderclap headache

• Sudden onset

• Like SAH

• Major complications

– Ischaemic or haemorrhagic stroke

• Diagnosis

– CT –tive SAH

– Normal LP

– Cerebral angiogram

Case report: Headache back!

• Persistent occipital headache

• Intermittent / throbbing

• Non-postural

• Increasing sedation/confusion

Postpartum

Neurology opinion

• Migraine

• Analgesics / fluids

Postpartum: Day 5 (night)

• 4 Grand Mal seizures

Portrait of a Man After a Grand Mal Seizure

Postpartum: Day 5 (night)

• 4 Grand Mal seizures

• Treatment

– Diazepam & phenytoin

• On examination

– No focal neurology

– No papilloedema

– No hypertension

– Normal bloods

• CT/MRI

Portrait of a Man After a Grand Mal Seizure

MRI Scan

MRI Scan: cortical vein thrombosis

Cerebral vein thrombosis

• 8.9 cases / 100 000

deliveries in USA

• 2 deaths in ’94-’96 CEMD

• MRI diagnostic in 90% cases

• Mortality 28 - 33%

Stocks ’00

Cerebral Vein Thrombosis

• Headache/papilloedema

• Seizures/hemiplegia

• Coma

• Thrombotic tendency

– Pregnancy

– Protein C, S

• MRI

Further Management

• Transferred to neurology unit

• Lumbar puncture:- xanthochromia

• Coagulant screen:- normal

• NOT anticoagulated

• Full recovery

• Avoid oral contraceptives

Headache investigation


Meningitis


Postural

Meningitis


Postural

PDPH

Meningitis


Postural

PDPH

Empirical

MRI gadolinium

LP

CT myelogram

Meningitis

Low pressure headache

Mokri ’99 gadolinium scan


Postural

PDPH

Empirical

MRI gadolinium

LP

CT myelogram

Meningitis


Postural Previous Hx

PDPH

Empirical

MRI gadolinium

LP

CT myelogram

Meningitis


Postural Previous Hx

PDPH

Empirical

MRI gadolinium

LP

CT myelogram

Migraine

ICHD criteria

Meningitis


Postural Previous Hx Abrupt/gradual

PDPH

Empirical

MRI gadolinium

LP

CT myelogram

Migraine

ICHD criteria

Meningitis



PDPH

Empirical

MRI gadolinium

LP

CT myelogram

Migraine

ICHD criteria

CVT SAH RCVS

Meningitis



PDPH

Empirical

MRI gadolinium

LP

CT myelogram

Migraine

ICHD criteria

CVT SAH RCVS

MRA/MRV

LP

Plain CT

Meningitis


Postural Previous Hx HT/Proteinuria Abrupt/gradual

PDPH

Empirical

MRI gadolinium

LP

CT myelogram

Migraine

ICHD criteria

CVT SAH RCVS

MRA/MRV

LP

Plain CT

Meningitis


Postural Previous Hx HT/Proteinuria Abrupt/gradual

PDPH

Empirical

MRI gadolinium

LP

CT myelogram

Migraine

ICHD criteria

CVT SAH RCVS

PET

MRA/MRV

Empirical

LP

Plain CT

Meningitis


Postural Previous Hx Vasopressors HT/Proteinuria Abrupt/gradual

PDPH

Empirical

MRI gadolinium

LP

CT myelogram

Migraine

ICHD criteria

CVT SAH RCVS

PET

MRA/MRV

Empirical

LP

Plain CT

Meningitis


Postural Previous Hx Vasopressors HT/Proteinuria Abrupt/gradual

PDPH

Empirical

MRI gadolinium

LP

CT myelogram

Migraine

ICHD criteria

CVT SAH RCVS

PET RCVS

MRA/MRV

MRI/MRV Empirical

LP

Plain CT

Meningitis

headaches, headaches and more headaches. diagnostic ... nov 1630 stocks…dural venous sinus...

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