Christy Stierwalt: A 28-Year-Old Librarian With Postdural Headache Following an Epidural Block for Vaginal Delivery





Learning Objectives





  • Learn the common types of headache.



  • Understand the difference between primary and secondary headaches.



  • Develop an understanding of clinical presentation of specific headache types.



  • Develop an understanding of the treatment of specific headache types.



  • Develop an understanding of the differential diagnosis of postdural headache.



  • Learn how to identify factors that cause concern.



Christy Stierwalt





Christy Stierwalt is a 28-year-old librarian who is a gravida 2, para 2 with the chief complaint of, “Every time I sit up it feels like my head is going to explode.” Christy was lying flat on the examination table with a pillow under her feet when I entered the room. She tried to sit up but immediately grabbed her head, lay back down and said, “Sorry, Doctor, the pain is just too bad when I try to sit up.” Christy went on to say that as long as she stayed lying flat, she was fine, but as soon as she sat up to nurse or got up to the bathroom, her entire head starting pounding. The longer she stayed up, the worse the headache got, and then she got really nauseated. “Doctor, I apologize for my appearance. I haven’t been able to wash my hair or clean up since I delivered. I know I must look a mess.” I reassured her that she looked fine and that we were going to figure out what was going on and get her better so she could enjoy her beautiful new baby. I asked if there were any problems with the delivery, and Christy shook her head and said that other than being really numb for a long time after she delivered, it was a piece of cake. She volunteered that she didn’t remember being that numb with her first epidural, but the numbness went away and then the headaches started. She said that the nurse told her to drink a lot of fluids and try to lie flat and that the headaches would go away. She said she drank a lot of fluids, but that made her get up to go to the bathroom, and getting up caused the headaches. “Kind of a vicious cycle, don’t you think, Doctor? I can’t just stay in bed! My mom came to help, but she can’t miss much more work, and my husband travels. I really need to get rid of these headaches.”


I asked Christy if she had any other symptoms that went along with the headache and she said that other than the nausea, there was nothing else but the headache. I asked Christy if she had identified anything that triggered her headache and she immediately answered, “Anytime I try to get up. And I mean anytime . There is no break, just trying to sit up a little to nurse and my head is killing me.” I asked if she had any fever or stiff neck and she shook her head no.


I asked her what made it better and she said, “Pain meds do absolutely nothing but upset my stomach. As long as I lie flat, I am fine, but drinking fluids, a glass of wine, caffeine, nothing else helps at all.”


I asked Christy to use one finger to point at the spot where it hurt the most. She said there was nothing to point at when she was lying flat, but if she sat up, it was her entire head. I asked her what the pain was like: an ache, sharp, stabbing, pounding, burning? She immediately said, “Pounding. It feels like my head is going to explode. The worst throbbing you can imagine, and if I don’t lie down, it just gets worse and worse.” I asked Christy from the time that she sat up, how long was it until she started having headache pain. She said, “It’s almost immediate, and it worsens very quickly if I don’t lie right back down.”


On physical examination, Christy was afebrile. Her respirations were 16 and her pulse was 78 and regular. Her blood pressure was 126/80. Fundoscopic examination was normal, but Christy had an obvious sixth cranial nerve palsy on the left ( Fig. 7.1 ). I asked if she had noticed anything funny going on with her eyes, and she said that her husband had said the headaches were making her “cross-eyed,” but she thought he was just kidding around. There were no other cranial nerve abnormalities, and the remainder of her head, eyes, ears, nose throat (HEENT) examination was completely normal. Her cervical paraspinous muscles were mildly tender, but no myofascial trigger points were identified. Her cardiopulmonary examination was normal, as was her thyroid. Her abdominal examination revealed no abnormal mass or organomegaly, and there was no rebound tenderness present. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. A careful neurologic examination of the upper and lower extremities revealed no evidence of weakness, lack of coordination, or peripheral or entrapment neuropathy, and her deep tendon reflexes were normal. Christy’s mental status exam was within normal limits. I asked Christy to try and sit up, which immediately triggered her headache, so I put her flat. I told her that I was pretty sure I knew what was going on, and the good news was there was an easy fix to get rid of her headaches. She smiled and said, “That’s why you get paid the big bucks!”




Fig. 7.1


(A) Idiopathic left sixth nerve palsy causing left lateral rectus weakness and limitation of abduction in a young adult. (B) Conjugate gaze to the right is normal.

From Liu G, Volpe N, Galetta S, et al. Galetta’s Neuro-Ophthalmology . ed. 3. New York: Elsevier; 2019 [Fig. 15.37a-b].




Key Clinical Points—What’s Important and What’s Not


The History





  • Recent onset of postdural headache following an epidural block for vaginal delivery



  • Headache occurs when patient moves from supine to sitting position



  • Headache resolves when patient returns to supine position



  • Headaches are holocranial



  • Character of the headache pain is throbbing



  • Patient denies fever or chills



  • Patient notes the onset of nausea if remaining in the upright position



  • Significant disability associated with headache; specifically, patient is unable to care for her newborn



The Physical Examination





  • Patient is afebrile



  • Normal fundoscopic exam



  • Left sixth cranial nerve palsy is noted



  • Neurologic exam is otherwise normal



  • Headache triggered by moving patient from supine to sitting position



Other Findings Of Note





  • Normal cardiovascular examination



  • Normal pulmonary examination



  • Normal abdominal examination



  • No peripheral edema



  • Normal upper and lower extremity neurologic examination, motor and sensory examination



What Tests Would You Like to Order?


The following tests were ordered:




  • No tests were ordered.



Test Results


None


Clinical Correlation—Putting It All Together


What is the diagnosis?


Postdural puncture headache


The Science Behind the Diagnosis


Clinical Syndrome


When the dura is intentionally or accidentally punctured, the potential for headache exists. The clinical presentation of postdural puncture headache is classic and makes the diagnosis straightforward if considering this diagnostic category of headache. The diagnosis may be obscured if the clinician is unaware that dural puncture may have occurred, or in the rare instance when this type of headache occurs spontaneously after a bout of sneezing or coughing. The symptoms and rare physical findings associated with postdural puncture headache are due to low cerebrospinal fluid pressure resulting from continued leakage of spinal fluid out of the subarachnoid space.


The symptoms of postdural puncture headache begin almost immediately after the patient moves from a horizontal to an upright position ( Fig. 7.2 ). The intensity peaks within 1 or 2 minutes and abates within several minutes of the patient again assuming the horizontal position. The headache is pounding in character, and its intensity is severe, with the intensity increasing the longer the patient remains upright. The headache is almost always bilateral and located in the frontotemporal, and occipital regions. Nausea, vomiting, and dizziness frequently accompany the headache pain, especially if the patient remains upright. The headache gradually resolves within 30 minutes of the patient resuming the supine position.


Apr 16, 2022 | Posted by in PAIN MEDICINE | Comments Off on Christy Stierwalt: A 28-Year-Old Librarian With Postdural Headache Following an Epidural Block for Vaginal Delivery
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