A 20-year-old woman had a Caesarian section at 39 weeks. She had a history of migraine, but this headache was different. Her request for “something really strong” for the pain was cause for concern.
A 20-year-old G3P2 with asthma, chronic hypertension, gestational diabetes and morbid obesity had a Caesarian section at 39 weeks. The baby boy was a healthy 10 pounds, but the patient developed headache after epidural anesthesia. She complained of throbbing pain over her whole head with some nausea. The pain increased with activity.
Despite ibuprofen, acetaminophen/butalbital/caffeine and prochlorperazine, the headache continued. The patient requested “something really strong” for the pain. There was concern for drug-seeking behavior. Three days postpartum, anesthesia performed a blood patch with some improvement. She was discharged the next day without opioids.
Three days later, the patient returned to the ER, complaining of persistent headache. Physical and neurological examination were normal. The patient was sent for a CT scan of the brain.
Brain CT scan with contrast revealed a filling defect in the posterior aspect of the superior sagittal sinus (Figure 1). On the axial view, the bean-shaped low-density filling defect likely represents thrombus (Figure 2). This filling defect is consistent with the “empty delta sign,” which is typically triangular.1
Figure 1. Brain contrast sagittal CT with filling defect in the posterior superior sagittal sinus (arrow).
Figure 2. Brain contrast axial CT with filling defect in the posterior superior sagittal sinus (arrow).
Hospital course. Tests for coagulopathy were negative. The patient was discharged on subcutaneous heparin (enoxaparin 120 mg BID) for 6 months.
Outpatient treatment. The headache resolved after several weeks. A follow up scan six months after discharge demonstrated resolution of the cerebral venous sinus thrombosis. The enoxaparin was discontinued.
Discussion. Headache occurs in more than a third of all pregnancies.2 While more than half of these headaches are benign primary headaches, the remainder have secondary etiologies, some of which are life-threatening. The most common etiologies for secondary headaches during pregnancy include cerebral infection, cerebral venous sinus thrombosis, hypertension, intracranial hemorrhage, and stroke.2 Evidence of these will generally be visible on neuroimaging.
A careful history and physical examination are required in order to differentiate benign from malignant headache. “Red flags” include acute hypertension, change from a prior headache pattern, fever, sudden onset, and/or physical findings such as a stiff neck or focal neurological signs.2 Although the patient had a history of migraine, this headache had a different pattern. Pregnancy and puerperium are among the many risk factors for cerebral venous sinus thrombosis, which complicates 1/10,000 pregnancies. This diagnosis must be considered when pregnant or postpartum women complain of headache, seizures, or other central nervous system symptoms or signs.3
This patient complained of persistent headache, initially attributed to the epidural (spinal headache) and possible drug-seeking behavior. Post-dural puncture headache after caesarian section is not uncommon, affecting 10% to 30% of patients.4 When the headache persisted for several days despite blood patch treatment, other etiologies were considered. Neuroimaging revealed thrombosis in the superior sagittal sinus, the most common region for cerebral sinus thrombosis.1 In cases of cerebral venous sinus thrombosis presenting with headache as the only symptom, the prognosis, as in this case, is excellent.3
1. Lee EJY. The empty delta sign. Radiology. 2002;224:788-789.
2. Raffaelli B, Neeb L, Israel-Willner H, et al. Brain imaging in pregnant women with acute headache. J Neurol. 2018;265:1836-1843.
3. Kashkoush AI, Ma H, Agarwal N, et al. Cerebral venous sinus thrombosis in pregnancy and puerperium: A pooled systematic review. J Clin Neurosci. 2017;39:9-15.
4. Yang CJ, Chen T, Ni X et al. Effect of pre-administration with aminophylline on the occurrence of post-dural puncture headache in women undergoing caesarean section by combined spinal-epidural anesthesia. J Int Med Res. 2018 Oct [Epub ahead of print].
Dr Wilner is Associate Professor of Neurology at the University of Tennessee Health Science Center and a staff physician at Regional One Health in Memphis, TN. His upcoming book is The Locum Life: A Physician's Guide to Locum Tenens. Website: andrewwilner.com. Twitter: @drwilner. Dr Wilner is an editorial board member of Neurology Times.