Critical cases: Post-partum headache!


  • 22 yo F 3 weeks postpartum after uncomplicated SVD presents with severe headache and neck pain  worsening over 24 hours
  • Headache localized posterior and retro-orbital
  • One episode vomiting
  • No vision changes, fever, or neurologic complaints


Physical exam:

  • Vitals: afebrile, HR 97, BP 146/72
  • General appearance: Pt appears uncomfortable, supine on stretcher
  • Neuro: awake, alert and oriented. CN 2-12 intact, no oculomotor palsies or visual field deficits, no facial droop or slurred speech. No focal weakness. Gross sensation intact. No dysmetria. Normal tandem gait



  • Primary headache, Cerebral venous thrombosis (CVT), Preeclampsia, Post-dural puncture headache (patient had epidural during labor), Idiopathic intracranial hypertension (pseudotumor cerebri), Meningitis,  Intracranial mass lesion (tumor vs abscess), Intracranial hemorrhage


Initial workup:

  • Lab findings: normal D-dimer, no leukocytosis, mild anemia
  • Urgent imaging: non-contrast CT head, which showed focal hypodensity concerning for edema vs venous infarct


Next steps:

  • Contrast enhanced MR venography: abnormally low signal/absence of flow in the left transverse sinus, suggesting thrombosis



  • Early anticoagulation! Patient was started on subcutaneous LMWH, admitted and bridged to Warfarin


Take home points:

  • Cerebral venous thrombosis is rare, but should always be considered in patients with prothrombotic conditions
  • Clinical presentation is highly variable - onset can be acute, subacute, or chronic.
  • Headache is the most frequent symptom.
  • Head CT scan is normal in up to 30 percent of CVT cases, and most of the findings with CVT are nonspecific.
  • CTV or MRV is the best imaging modality for confirming diagnosis
  • Tx = Anticoagulation with LMWH or unfractionated heparin