A 21-year-old woman is evaluated for nausea, vomiting, and a severe headache. The patient developed a headache last night after getting out of bed and walking to the newborn nursery. Her headache has not improved with acetaminophen or ibuprofen, and the only thing that makes it better is lying down and sleeping. Now she has a severe headache, nausea, and vomiting whenever she gets out of bed. The patient has had no dizziness, changes in vision, or loss of consciousness. She had a spontaneous vaginal delivery 2 days ago after an induction of labor for gestational hypertension. She had an epidural placed for analgesia that was removed immediately after delivery. Temperature is 37.2 C (99 F), blood pressure is 136/88 mm Hg, and pulse is 108/min. The patient has neck stiffness and is unable to sit up due to severe nausea. There is no papilledema, and the pupils are equal and reactive. Bilateral lower extremities have pitting edema to the knees. Deep tendon reflexes are 2+. Which of the following is the most likely diagnosis in this patient?

Question

A 21-year-old woman is evaluated for nausea, vomiting, and a severe headache.  The patient developed a headache last night after getting out of bed and walking to the newborn nursery.  Her headache has not improved with acetaminophen or ibuprofen, and the only thing that makes it better is lying down and sleeping.  Now she has a severe headache, nausea, and vomiting whenever she gets out of bed.  The patient has had no dizziness, changes in vision, or loss of consciousness.  She had a spontaneous vaginal delivery 2 days ago after an induction of labor for gestational hypertension.  She had an epidural placed for analgesia that was removed immediately after delivery.  Temperature is 37.2 C (99 F), blood pressure is 136/88 mm Hg, and pulse is 108/min.  The patient has neck stiffness and is unable to sit up due to severe nausea.  There is no papilledema, and the pupils are equal and reactive.  Bilateral lower extremities have pitting edema to the knees.  Deep tendon reflexes are 2+.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_da5e_422b_bc81_bb55f0fdb6f9_MD0003_00 This postpartum patient with a severe headache after recent epidural anesthesia most likely has a postdural puncture headache. During placement of neuraxial anesthesia, unintentional dural puncture may occur, causing cerebrospinal fluid leakage, low cerebrospinal fluid pressure, and resultant slight herniation of the brain and brainstem. Therefore, patients can develop a positional headache (ie, headache worsens when sitting or standing and improves with lying down), which correlates with the increased and decreased herniation/pressure on the brain, within 72 hours of the procedure. Other associated symptoms may include nausea, vomiting, and neck stiffness. Most postdural puncture headaches are self-limited; however, patients with severe symptoms that interfere with activities of daily living can be treated with an epidural blood patch. (Choice A) Bacterial meningitis can occur as a complication of epidural placement and present with headache and neck stiffness; this diagnosis is unlikely because this patient has no fever or altered mental status. (Choice B) Benign paroxysmal positional vertigo presents with positional nausea and vomiting (and occasionally headache), but this patient has no dizziness, making this diagnosis unlikely. (Choice C) Migraine headaches can be associated with nausea, vomiting, and neck stiffness; they are often improved with sleep and being in a dark room. However, patients do not typically have worse pain with standing (ie, not positional) and do not have the frequency of headache seen in this patient (ie, every time she stands). (Choice E) Preeclampsia with severe features can develop postpartum, particularly in patients with gestational hypertension, and present with headache and edema. However, headaches due to preeclampsia are not positional. In addition, this patient is normotensive with normal deep tendon reflexes, making this diagnosis less likely. (Choice F) Tension-type headaches may be associated with neck stiffness, but the pain is typically bandlike around the head and not altered by positioning. Educational objective: Postdural puncture headaches after neuraxial anesthesia (eg, epidural) occur due to unintentional dural puncture. Patients typically develop a positional headache (ie, worsens when upright, improves when supine) within 72 hours of the procedure and often have associated nausea, vomiting, and neck stiffness. References: Postdural puncture headache: an evidence-based approach. (http://www.ncbi.nlm.nih.gov/pubmed/28131118) PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies. (http://www.ncbi.nlm.nih.gov/pubmed/12734154)

A 21-Year-Old Woman Is Evaluated for Nausea, Vomiting, and a Severe