The term Postpartum refers to that period of time just after the delivery of a baby. Partum refers to the perfect passive participle of the Latin word pariō which means "I bring forth, give birth; acquire."  This refers to delivering a baby and “post” means “after”, so postpartum refers to the period of time after the delivery of a baby. 

After a baby is born there is usually a great change in the life and responsibilities of everyone in the household, namely the mother and father.  The first weeks at home with a newborn are joyful but also a challenge for all new parents. 

Twenty-five% of women have migraine and about 70% of them have a menstrual or estrogen relationship, usually with their cycle where estrogen is high for 3 weeks and then low for the next week.  Many women are not informed are warned about this migraine recurrence.

Pregnancy is a high estrogen time and migraine attacks are fewer during that time, only to come again after the baby is born and the menstrual cycle starts up again.  These headaches would be called:  Postpartum Migraine.

This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, and blogger.

Read my Mini eBook on Migraine here.

Post partum Migraine is the occurrence of severe, sudden migraine headaches that come after the  re-establishment of normal menstrual cycles after childbirth.  Estrogen rises for 3 weeks and then the headaches come as estrogen levels drop.  Many times, these headaches are somewhat worse than the patient’s usual previous migraine experience.

Some women present with their first migraine at the postpartum time, usually with the first baby.  The migraines come several days before, at the time of bleeding, or two days after bleeding.  Postpartum migraine may be delayed by breast feeding the baby.

Related questions.

How frequent is Postpartum Migraine?

One out of four of women will have a migraine within two weeks of delivery, and nearly half will have migraine attacks within the first month.

“In addition to that, about 5 percent of women who have never experienced a migraine get their first one in the postpartum period.  So, we’re talking about millions of women every year-that is a very high number.,” said Dr. Angeliki Vgontzas, a neurologist at the Brigham and Women’s Faulkner Hospital.

First time occurrence of Postpartum Migraine is very common but women in this situation are often poorly educated about what is happening and will need to establish a relationship with a neurologist and have testing with lab work and MRI scanning to sort things out to provide an accurate diagnosis and beneficial treatment.

Why do these bad Migraines occur just after childbirth?

Estrogen and progesterone levels during pregnancy are very high, and many women who had migraine before pregnancy will find their headache symptoms lessen or disappear during this time.

TIP In the best situation previous migraineurs should discuss the recurrence of migraine headaches with their doctor and plan for them with an adequate supply of migraine medication that previously worked on hand.

What are the migraine triggers after childbirth?

Sleep deprivation/frequent nocturnal awakenings. This is probably the #1 trigger. The mother may be up for night-time and early mornings feeding and caring for her new baby.

Try to take naps when your baby naps and ask your family or a friend to watch over the baby between feedings.

Stress/Overwork.  Try to relax to reduce stress. Take an easy walk or get mild exercise, read a book, get out of the house, or chat with a friend to alleviate stress.

Just having someone to help with caring for the baby so the mother can sleep can provide very great and significant maternal relief.

There will be stress from all that has to be done.

Mothers may need more help from husbands, other children in the house, mothers or mothers-in-law, sisters, or close friends.

These helpers can be organized so the new mother is not alone with her baby to deal with everything that needs to be done.

In the postpartum time a mother may be more concerned about the baby than their own health, but she may not be able to adequately care for her baby if she experiences disabling, severe migraine headache.

Migraine headaches are disabling and persons with a migraine usually need to sleep or lie quietly in bed and can’t be up and about doing things.

Dehydration  Drink plenty of fluid. Have a large water bottle nearby.

Irregular meals.  Eat well and avoid known personal food migraine triggers.  Mothers should eat healthy foods regularly.

As a preparation before delivery mothers should stock their refrigerator and pantry with nutritious foods that are convenient to prepare and eat.

Unknown family migraine link.

There may a family history of migraine which may relate to the mother, grandmother, aunt, or sister.  Many patients with migraine are not diagnosed and there are migraine pseudonyms or false names discussed in the family.  These may be:

Sick headache

Sinus headache

Menstrual headache

Hungry headache

One-sided headache

Nocturnal headache.

 The mother with Postpartum Migraine might have been told that their own mother or sister had these false migraine names and not recognize her family link to migraine which then puts her at risk for an attack of migraine.

 Migraine medication and whether or not to breast feed?

Migraine treatment and breast feeding may affect the baby.  Mothers and doctors worry about this.  But there are Migraine treatments that don’t affect the baby.  Sumatriptan, a successful migraine specific drug  may be safely used.

Caffeine, Tylenol, ibuprofen, and other NSAIDs may be safely used.

Breastfeeding itself may reduce the occurrence of migraine.

Breastfeeding mothers need to always determine if the medications they take are excreted in breast milk and where they are safe for their baby.

See my blog article on “Are Triptans safe to take while breastfeeding?”

The mother may start an estrogen-based contraceptive during the postpartum period.

The FDA has said that all estrogen-based contraceptives—the pill, the patch, or the shot are “contraindicated” with migraine.  Contraindicated here means “to not take.”

Starting a birth control pill can aggravate migraine occurrence.

The usual bottom line.

Most often, postpartum headaches are tension or migraine headaches, which may be treated at home or with the help of your doctor.

More severe secondary headaches should be seen by your doctor immediately and may require neurologic consultation, blood work, and MRI scanning.

Differential diagnosis and incidence of postpartum headaches

It may be that the headache the mother is experiencing is not Migraine.  What else could it be?

Different types of Postpartum Headaches:

Caffeine withdrawal headache.  Criteria for caffeine withdrawal—prolonged daily use of caffeine, abrupt cessation or reduction of total caffeine use, closely followed by headache and one or more of the following symptoms:  fatigue/drowsiness, anxiety/depression, nausea/vomiting, clinically significant distress or impairment in social, occupational or other important areas of functioning. 

Tension type headache.  This is the most prevalent type of headache.  It is about 70% of all headaches.  Tension Type Headache occurs on both sides of the head, and is described as pressing or tight, like a vise, or like a band around the head, and only mild or moderate in severity.  On a scale of 1-10 Tension Type Headache can only go to a 5.  Patients with TTH may carry tension in their neck, or shoulders, and have muscle spasm knots in the back of their neck.

Pre-eclampsia/eclampsia.  Preeclampsia is a serious, life threating medical condition that can occur before or after childbirth. It is associated with high blood pressure and protein in your urine. It can lead to seizures, a coma, or, left untreated, death.

Headache with pre-eclampsia may be pulsatile, bilateral, and worse with activity.  There may be visual changes, abdominal pain, decreased urinary output, and trouble breathing. 

Pre-eclampsia is a medical emergency requiring immediate medical assessment.

Post-dural puncture headache.  It may not have been just an epidural (above the dura) anaesthetic injection.  Sometimes the anaesthesiologist accidentally pushes the needle too far and penetrates the dura surrounding the lumbar spinal nerves.  Then a leak of spinal fluid may exist which later causes orthostatic headache, and a post- dural headache may occur.

Cortical vein thrombosis.  Pregnancy is a hypercoagulable state and sometimes the internal cerebral veins clot.  Symptoms of thrombosis may be:  headache, blurred vision, fainting or loss of consciousness, paralysis of part of the body like a stroke, seizures, and coma.

Subarachnoid haemorrhage.  Symptoms may be, sudden onset of the worst headache the patient  has ever experienced or imagined, seizure, double vision, neck and back pain, and coma.

Posterior reversible encephalopathy syndrome.   Abbreviated as PRES it presents with rapid onset of symptoms including headache, seizures, altered consciousness, and visual disturbance.  It may or may not be associated with acute hypertension.

Space-occupying lesion.  Brain tumours don’t usually, but may rarely, present with headache.  They usually present with paralysis, visual change, seizure, memory or speech problems. Subdural haematoma comes after a fall or a blow resulting in head injury.

Cerebral infarction/ischaemia.  This may be stroke symptoms like paralysis on one side of the body along with headache.

Maxillary Sinusitis.  Symptoms may be previous upper respiratory infection or allergic rhinitis symptoms followed by cheek, behind the eyes, or forehead headache along with green or yellow nasal discharge.

Meningitis.  This should be generalized headache, fever, and a stiff neck.  ER evaluation would be blood work, brain scanning, and lumbar puncture.

All these patients should be evaluated by a neurologist with blood work and scanning.

Breakdown of the frequency of occurrence of different types of Postpartum headache.

One study reported that in their sample group of 95 women with postpartum headache:

Fifty percent had tension type headache or migraine headache.

24 percent had a headache related to pre-eclampsia.

16 percent had a headache caused by regional anesthesia, i.e. post-dural puncture headache.

Postpartum Migraine review.

Hoshivama, et al. wrote in Intern Med. 2012;51(22):3119-23 on “Postpartum migraines: a long-term prospective study.”

This was an article in response to the lack of valid medical reports regarding the course of migraine during pregnancy.  The authors “investigated the patients suffering from migraines over a long postpartum period in an obstetrics department in Japan.”

This was a prospective study of “the course of migraines during the postpartum period by patients in a postnatal ward. The patients were surveyed during the first postpartum week and 1, 3, 6 and 12 months after delivery.

The patients were provided a headache diary to assess medication use and migraine attack frequency, severity (the faces pain scale) and duration.”

The migraine remission rate was 63%, 83% and 85% during the first, second and third trimesters, respectively.

No patient experienced a worsening of headaches during pregnancy.

Headache recurrence during the first month after delivery was more frequent in the patients >30 years of age than in those ≤30 years of age (p<0.05).

The percentage of women experiencing recurrence at 1, 3, 6 and 12 months after delivery was 63%, 75%, 78% (n=60) and 87.5% (n=40), respectively.

In breastfeeding patients, the rates were 50%, 65.8%, 71.1% and 91.7% and in bottle feeding patients, the rates were 86.4%, 90.9%, 95.5% and 81.3%, respectively.

Hoshivama, et al. concluded:

“that 85% of the patients with migraines experience remission during pregnancy and that more than 50% experience recurrence during the first month after delivery.

Until six months after delivery, breastfeeding is associated with a lower recurrence rate than bottle feeding.”

Check out my Big Migraine book here.

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All the best.

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Britt Talley Daniel MD