Pertinent History

A 29-year-old woman with a history of Crohn’s disease and migraine with aura presented to the emergency department (ED) with a headache. She is 4 weeks postpartum following a term pregnancy and uncomplicated vaginal delivery. She noted that the headache started approximately 5 hours ago with no appreciable trigger, but it “does not feel like my typical migraines.” She is usually able to treat her headaches with 400 mg of ibuprofen and a nap. Today, however, this did not improve her symptoms and instead the pain was slowly worsening. Initially her only symptom was the headache, but now she noticed that “my vision seems a little blurry.” This is not like her usual visual aura, which typically includes flashes of color.

She denied sick contacts, had no recent history of travel, ingestions, or environmental exposures. She denied numbness, tingling or focal weakness. She has had no fever or chills at home and no neck pain or rashes. She does endorse nausea but no vomiting. Of note, she recently restarted her oral contraceptive pill (OCP). She has a carbon monoxide detector at home.

Emergency Department Management

Our differential diagnosis included the following: Headache such as migraine, tension, or cluster type as well as atypical migraine, idiopathic intracranial hypertension, subarachnoid hemorrhage, stroke, intracranial mass, preeclampsia, and trigeminal neuralgia and carbon monoxide poisoning.

The patient was treated symptomatically for her headache with Toradol 15 mg IV, Benadryl 25 mg PO, and Compazine 10 mg IV with minimal improvement. About 30 minutes later, the patient had one episode of non-bloody, non-bilious emesis. Lab results and chest x-ray were unremarkable (listed later), showing no evidence of proteinuria to suggest postpartum preeclampsia. A CT head noncontrast was negative for any acute intracranial hemorrhage, large mass, or stroke.

Further attempts at pain control continued to have minimal effect. Given her history regarding being 4 weeks postpartum and recently restarting her estrogen-containing OCP, she was identified to be in a hypercoagulable state. Further history then revealed a family history of DVTs and that the patient had recently resumed smoking cigarettes to cope with the stresses of motherhood. At that time, the patient reported that her headache was worsening and that her vision was becoming blurrier. Visual acuity testing showed diminished acuity bilaterally. Ophthalmology was then consulted, and dilated fundoscopic exam revealed bilateral papilledema. Given these findings, neurology was consulted for increasing suspicion of increased intracranial pressure and recommended lumbar puncture. This revealed an elevated opening pressure but was negative for meningitis and subacute subarachnoid hemorrhage.

Pertinent Diagnostic Testing

Complete blood count , electrolytes, liver function tests, uric acid, lactate dehydrogenase, and urinalysis were within normal limits.

Urine pregnancy: Negative.

Carboxy hemoglobin was 5% (normal is <3% in nonsmokers and up to 10–12% in smokers).

Chest X-ray: No acute cardiopulmonary findings.

CT head (non-contrast): No acute intracranial abnormality.

Lumbar Puncture: Opening pressure 29 mmHg (normal <20 mmHg), RBC: 0–5 (normal =0), WBC: 0–5 (normal <5).

Introduction/Background

Physiology/Pathophysiology

Dural Sinuses