Hemicrania continua postpartum.
ABSTRACT Hemicrania continua is a common, but unrecognized headache disorder. We describe two patients with hemicrania continua whose symptoms started in the postpartum period, coined as hemicrania continua postpartum.
[show abstract] [hide abstract]
ABSTRACT: Headache is a common finding in the postpartum period, and there are limited data describing the cause and treatment of women with postpartum headache. Our objective was to describe our experience with women who were hospitalized for postpartum headache and to develop a management algorithm for these women. Data for 95 women with headache >24 hours after delivery from 2000-2005 were reviewed retrospectively. Maternal assessment included an evaluation for benign and serious causes of headache that included preeclampsia, dural puncture, and neurologic lesions. Neurologic imaging were performed on the basis of initial neurologic findings and clinical course. Outcomes that were studied included cause, a need for cerebral imaging, neurologic findings, maternal complications, and long-term follow-up evaluations. The mean onset of headache was 3.4 days (range, 2-32 days) after delivery. Tension-type/migraine headache was the most common cause (47%). Preeclampsia/eclampsia and spinal headache comprised 24% and 16% of cases, respectively. Anesthesia evaluation was required in 15 patients because of suspected spinal headache; blood patch was required in 12 of these patients. Cerebral imaging was performed in 22 patients because of focal neurologic deficits and/or failure to respond to initial therapy; 15 of these women (68%) had abnormal findings. Ten patients had serious cerebral pathologic findings, such as hemorrhage, thrombosis, or vasculopathy. There were no deaths; 2 women had minor residual neurologic damage on follow-up evaluation. The evaluation of persistent headaches that develop >24 hours after delivery must be performed in a stepwise fashion and requires a multidisciplinary approach. Preeclampsia should be considered initially in women with hypertension and proteinuria. Normotensive women should be evaluated initially for tension-type/migraine headache or spinal headache. Patients with headache that is refractory to usual therapy and patients with neurologic deficit require cerebral imaging to detect the presence of life-threatening causes.American journal of obstetrics and gynecology 04/2007; 196(4):318.e1-7. · 3.28 Impact Factor
© Blackwell Publishing Ltd
, 603–604 603
Blackwell Science, Ltd
1468-2982Blackwell Publishing, 2004
Hemicrania continua postpartum M Spitz & MFP Peres
Hemicrania continua postpartum
M Spitz & MFP Peres
Hospital Israelita Albert Einstein, São Paulo, Brazil
Spitz M & Peres MFP. Hemicrania continua postpartum. Cephalalgia 2004; 24:603–
604. London. ISSN 0333-1024
Hemicrania continua is a common, but unrecognized headache disorder. We
describe two patients with hemicrania continua whose symptoms started in the
postpartum period, coined as hemicrania continua postpartum.
Mario F. P Peres Instituto de Ensino e Pesquisa, Hospital Israelita Albert Einstein. Av
Albert Einstein, 627/701, São Paulo SP, 05651-901. E-mail email@example.com
Received 4 November 2003, accepted 12 December 2003
Hemicrania continua (HC) was previously thought
to be a rare disorder, however, recent studies have
shown it is a underrecognized primary headache (1).
HC is characterized by a continuous, moderate to
severe, unilateral headache, absolutely responsive
to indomethacin. Pain exacerbation is frequently
accompanied by migrainous (nausea, photophobia,
phonophobia) and autonomic features (ipsilateral
ptosis, conjunctival injection, lacrimation, nasal con-
gestion) (2, 3).
Hemicrania continua is more prevalent in women
than men (2 : 1), and usually occurs during the
reproductive life. Little is known about reproductive
life events effects in the course of hemicrania con-
tinua. Hemicrania continua postpartum has never
We report 2 patients with hemicrania continua
whose symptoms started in the postpartum period.
Case 1 is a 29-year-old white woman with a 2-month
history of headaches starting in the postpartum
period, 12 h after a cesarean section. The pregnancy
was unremarkable, a healthy baby was delivered
without complications. A spinal anaesthesia was
performed, however, the headache did not change
in quality nor intensity according to position. The
headaches were hemicranic, strictly left-sided. A
continuous, moderate intensity headache was
present and pain exacerbations occurred three to
four times a week, lasting six to eight hours. Head-
aches were accompanied by unilateral tearing, con-
junctival injection and a ‘sand in the left eye’
sensation. Photophobia and phonophobia were
present in the exacerbation period, without nausea
or vomiting. The patient denied a previous history
of headaches. Neurological examination was
normal. Magnetic resonance imaging (MRI) of the
brain and the MRAngiogram were normal. The
patient had complete alleviation of her headache
with indomethacin, 75 mg a day. Attempts to
decrease the indomethacin dose followed by return
of headaches. Three months after inititating therapy
the patient had a remission lasting 5 weeks without
medication, then the headache returned with the
same characteristics and once again responded to
Case 2 is a 32-year-old white female with a 2-year
history of unilateral headaches after delivery of her
first child. The patient denied a previous history of
M Spitz & MFP Peres
© Blackwell Publishing Ltd
headaches. Pregnancy was normal and a normal
vaginal delivery with local anaesthesia was per-
formed without complications. Her headaches were
strictly unilateral, left-sided, fronto-temporal loca-
tion and of continuous, moderate intensity. Pain
exacerbations occurred on a daily basis, lasting four
to eight hours. Headaches were accompanied by
tearing, ipsilateral to the pain. Photophobia, phono-
phobia, nausea and vomiting were present during
the exacerbation period.
Neurological examination, MRI and MRA of the
brain were normal. Acute treatments, including
sumatriptan, zolmitriptan, naratriptan, rizatriptan,
ergotamine, dipyrone, paracetamol, naproxen and
diclofenac, were tried without success. The patient
had overused acute medications for one year, but not
for the past six months. Preventive medications such
as amitryptiline, propranolol and flunarizine, in
adequate dosages, also failed even in the absence
of rebound headache. The patient had a partial
response with indomethacin 75 mg a day and a com-
plete headache relief with 150 mg a day.
Hormone-related headaches are common. Migraine
is more likely to change during reproductive life
Headache generally improves with rising oestro-
gen levels and worsens with falling levels. It should
therefore improve with pregnancy and worsen post-
partum. Oestrogen influences pain by its ability to
alter neural function, as well as neurotransmitters
levels. As oestrogen incresases, there is a corre-
sponding increase in peripheral serotonin, resulting
in increased inhibition on headache pathways (4).
Although postpartum headaches are usually
benign, secondary pathology must be excluded (5).
The differential diagnosis of headache in the post-
partum period includes postdural headache, pre-
eclampsia, cerebral venous thrombosis, cerebral
angiopathy and also primary headaches, particu-
Stein (6) followed 71 women prospectively during
their first postpartum week. Headache occurred in
27 (39%) of the women and was most frequent on
days 3–6 post partum. Headache was associated
with a previous history or family history of migraine
(58% of migraineurs developed headache). These
headaches were less severe than the patients’ typical
migraine headache. Cupini et al. (7) found 7% of
patients with migraine without aura started their
symptoms in the postpartum period.
Hemicrania Continua has never been reported
in the postpartum period. The pathophysiology of
hemicrania continua postpartum is unknown.
1 Peres MF, Silberstein SD, Nahmias S, Shechter AL, Youssef
I, Rozen TD, et al. Hemicrania continua is not that rare.
Neurology 2001; 57:948–51.
2 Peres MF. Hemicrania continua: recent treatment strategies
and diagnostic evaluation. Curr Neurol Neurosci Rep 2002;
3 Newman LC. Cluster and related headaches. Med Clin
North Am 2001; 85:997–1016.
4 Marcus DA, Scharff L, Turk D. Longitudinal prospective
study of headache during pregnancy and postpartum.
Headache 1999; 39:625–32.
5 Evans RW, Wilson MC. Postpartum headaches. Headache
6 Stein GS. Headaches in the first post partum week and their
relationship to migraine. Headache 1981; 21:201–5.
7 Cupini LM, Matteis M, Troisi E, Calabresi P, Bernardi G,
Silvestrini M. Sex-hormone-related events in migrainous
females. A clinical comparative study between migraine
with aura and migraine without aura. Cephalalgia 1995;