Postpartum headache is a common presenting symptom that can be associated with multiple serious conditions, including postpartum preeclampsia, spontaneous subarachnoid hemorrhage (sSAH), and reversible cerebral vasoconstriction syndrome (RCVS). Each one of these conditions can present with severe headache, but sSAH is typically minimal in volume and not associated with cerebral vasospasm. RCVS on the other hand can cause spontaneous convexial subarachnoid hemorrhage (sSAH) with prolonged vasospasm, that can endanger the patient’s life.

40-year-old G2P2, n0n-smoker female, with no significant medical history, presented on postpartum day four with severe headache and hypertension. She was diagnosed as postpartum preeclampsia, that was managed with magnesium sulfate and antihypertensives. Four days later, despite optimal treatment, the persistent headache prompt a CT scan of the head that revealed a small-volume convexial subarachnoid hemorrhage and a diagnosis of sSAH was made. Head CT angiogram and Diagnostic cerebral angiogram (DCA) were performed and both came negative for aneurysms. One week later, despite of medical management, her headache persisted that prompt another DCA that showed severe, bilateral diffuse cerebral vasospasm. Over a two-weeks period, the cerebral vasospasm was monitored with repeated transcranial doppler and brain imaging, which revealed progressive cerebral vasospasm. The persistence of vasospasm despite of the optimal medical management in the setting of spontaneous convexial subarachnoid hemorrhage supported RCVS as a final diagnosis. Patient's headache improved, and her vasospasm began to resolve after three weeks of hospitalization. She was discharged with instructions for outpatient follow-up and repeat brain imaging after twelve weeks.

Differential diagnosis of postpartum headache can be very challenging due to the overlapping clinical features of postpartum preeclampsia, sSAH, and RCVS. Postpartum headache should prompt consideration of these differential diagnoses with careful monitoring and follow-up imaging, to allow timely diagnosis and appropriate management of these potentially life-threatening conditions.