Case Challenge: Woman Presents to Emergency Department With Headache and Hypertension

Lisa M. Hollier, MD, MPH; Carolyn K. Holland, MD, Med; Brittany R. Behm, MPH; Eliza C. Miller, MD, MS; Jenna M. B. White, MD; Christopher M. Zahn, MD; Nicole D. Ford, PhD, MPH; Deborah Burch, DNP, RN; Bethany Scalise, BSN; Amy St. Pierre, MBA


September 23, 2022

Editorial Collaboration

Medscape &

Although most cases are diagnosed during the antepartum period, new-onset or de novo postpartum preeclampsia is increasingly being recognized as an important contributor to maternal morbidity and mortality in the postpartum period.[1] Seventy-five percent of deaths secondary to gestational hypertensive disorders occur after birth, with 41% in one study occurring more than 48 hours postpartum.[2]

While there is variability in definitions, postpartum preeclampsia is often defined by new onset of high blood pressure (systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg or both) on two occasions at least 4 hours apart or blood pressures > 160/110 mm Hg in the absence of other features. Although often accompanied by new-onset proteinuria, hypertension and other signs or symptoms of preeclampsia, like headache and right upper quadrant pain, may be present in some women in the absence of proteinuria. Hypertensive disorders that first present during pregnancy can be categorized as gestational hypertension, preeclampsia, or preeclampsia with severe features. Persistent systolic blood pressure ≥ 160 mm Hg, or diastolic blood pressure ≥ 110 mm Hg, is considered preeclampsia with severe features regardless of any prior diagnosis (gestational hypertension or preeclampsia) and regardless of any laboratory abnormalities or symptoms.

Read more in the American College of Obstetricians and Gynecologists (ACOG)
Practice Bulletin on Gestational Hypertension and Preeclampsia.

Postdural puncture headache (PDPH) after epidural analgesia is a potential complication of an unintended dural puncture, which occurs in approximately 1%-6% of epidural placements. Symptoms of PDPH typically occur within 48-72 hours and include a bilateral frontal or occipital headache that is worse in the upright position, along with nausea, neck pain, dizziness, visual changes, tinnitus, hearing loss, or radicular symptoms in the arms. This patient's symptoms were late in onset.

Idiopathic intracranial hypertension is characterized by elevated cerebrospinal fluid pressure and can cause two problems: severe headache and visual loss. Fundoscopic exam may detect papilledema resulting from increased intracranial pressure, which can result from a number of different causes, including idiopathic intracranial hypertension. If the elevated cerebrospinal fluid pressure remains untreated, permanent visual loss or blindness may result. A normal fundoscopic exam makes this diagnosis less likely.

Cerebral venous sinus thrombosis is an uncommon type of stroke overall but accounts for up to a third of maternal strokes. Pregnancy as a thrombogenic state is considered a risk factor. The headache of cerebral venous sinus thrombosis is typically described as diffuse and often progresses in severity over days to weeks. A minority of patients may present with thunderclap headache, suggestive of subarachnoid hemorrhage, and a migrainous type of headache has been described. On examination, papilledema and distention of the scalp veins may be noted.