Epidural for Childbirth and Migraine: What is the Connection?
The use of an epidural for anesthesia during delivery is used by over 50% of women in labor in the United States. The area (low back) is prepped and a needle is injected in between the vertebrae and then the anesthetic medication is delivered by a catheter placed between the epidural and spinal cord. If the needle is pushed in too far, it can pierce the membrane or “dura” that forms the spinal sac containing cerebrospinal fluid (CSF) surrounding the spinal cord. In this case, a small leak of CSF occurs into the epidural space. This causes a “low pressure” headache. However, this complication is uncommon and occurs < 1% of the time when an epidural is performed. This headache is severe enough that is can present like a migraine but is very positional in nature; sitting up or standing exacerbates the headache since the CSF would then move away from the brain due to gravity. Lying down would bring more of the CSF back around the brain, thereby relieving the headache to a degree.
Women with a history of migraine may be more prone to an epidural headache as they are more sensitive to changes in their environment including any change in cerebrospinal fluid pressure. Women with a history of migraine may also experience worsening of their migraines after delivery due to the marked drop in estrogen after delivery. To differentiate if a post-partum headache is migraine or an epidural headache, look for the following:
- If the headache occurs within 18 hours of the epidural and if the headache is better lying down and much worse when sitting or standing, it is probably an epidural headache and most likely is due to a CSF leak from the epidural needle piercing the dura surrounding the spinal cord.
- If the headache is not positional and hurts even when lying down and has associated symptoms of migraine such as nausea, vomiting, sensitivity to light and noise, then think migraine.
Treatment for an epidural headache can be symptomatic such as lying flat, drinking lots of fluids including caffeine, and bed rest. It usually resolves within 4-5 days. The leak may resolve spontaneously; if not, then an epidural blood patch can be very effective. A small amount of blood can be taken out of a woman’s vein in her arm and then injected in the area of the leak where the epidural needle had been injected. This blood patch treatment is effective over 85% of the time and usually relieves the headache in a few hours. On occasion, it may need to be repeated.
Treatment for migraine exacerbation after delivery can include most traditional migraine medications including Sumatriptan (Imitrex) injection, Ketorolac (Toradol) injection, Odansetron (Zofran) injection, and oral triptan medications. For some triptans, it may be recommended for the woman to pump and discard her breast milk for several hours after ingestion; however, Sumatriptan has been determined to be compatible with breast-feeding as are most anti-inflammatory medications such as Ibuprofen and Naproxen.
In summary, epidural anesthesia is common for women in labor and causes a severe headache less than 1% of the time. This type of headache usually resolves in 4-5 days and if severe, can be effectively treated with an epidural blood patch.
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