. there may also be considerable overlap in the presentation of these conditions , making diagnosis and treatment difficult . interventions appropriate for the diagnosis and treatment of some of the conditions are contraindicated in others , making a carefully considered approach to these cases mandatory . we present a case of post - partum seizures and headache following a presumed dural puncture that highlights many of these issues and discuss the differential diagnosis and optimum management . a 20-year - old gravida 2 , para 1 ( g2 , p1 ) post - partum female presented to us with headache and seizures 4 days after a caesarean section . it was noted to be a difficult procedure , but a dural puncture was not recorded as having occurred . the epidural was extended for an emergency caesarean section due to poor progress of labour , and both the procedure and the immediate post - operative period were uneventful . on the first post - operative day , she complained of a postural frontal headache , which was treated with bed rest , intravenous fluids and simple analgesics . she presented to the emergency department the following day with generalised tonic - clonic seizures preceded by nausea and headache . there was no history of visual disturbances , raised temperature , tinnitus or neck rigidity . glasgow coma scale ( gcs ) was 8/15 with normal peripheral neurological reflexes and equally reacting pupils . she was afebrile with a pulse rate of 114 beats / min , blood pressure of 108/46 mmhg and spo2 ( oxygen saturation ) of 98% on 5 l / min oxygen . obstetricians treated her with magnesium sulphate and obtained a computerized tomography ( ct ) scan of the head , which did not reveal any abnormality . routine investigations showed a haemoglobin of 10 g / dl , white cell count ( wcc ) of 15.910/l , platelets of 10210/l , normal urea , electrolytes , clotting , liver function tests , uric acid and no proteinuria . gcs improved over the next few hours to 15/15 , and at this point we were asked to assess and advise on her further management . as eclampsia seemed an unlikely diagnosis , magnesium sulphate was stopped . a lumbar puncture with a 27 g spinal needle revealed clear cerebrospinal fluid , raised protein of 715 mg / l ( normal range : 120600 mg / l ) and no cells . a loading dose of intravenous phenytoin was administered and close electrocardiographic ( ecg ) monitoring was instituted in the labour ward . there were no further episodes of seizures and , after 24 h , her only symptom was a severe postural headache ( aggravated by upright position and relieved on lying supine ) . neurologists were consulted , who requested a magnetic resonance imaging ( mri ) scan and a magnetic resonance ( mr ) venous angiogram of the head . a consensus between the anaesthetists , neurologists , obstetricians and radiologists attributed dural puncture as the most likely cause for the headache . an epidural blood patch was discussed as a treatment option on the eighth post - partum day . after patient consent , 20 ml of sterile blood withdrawn from the ante - cubital fossa prepared with chlorhexidine solution 0.5% was injected into the epidural space aseptically without any complications . there was an almost immediate resolution of headache and the patient was discharged home the next day for further follow - up . the typical clinical features and dramatic improvement following epidural blood patch makes us confident that an unrecognised dural puncture was the cause of headache and seizures . headache and seizures in the post - partum period can present a diagnostic challenge . published case reports have described cases of post - partum seizures associated with dural puncture in the absence of any other cause for the seizures.[14 ] this case confirms the association , but many other conditions need to be excluded before a diagnosis can be made with confidence [ table 1 ] . the symptoms and signs of dural puncture and its complications and other causes of post - partum seizures include headache , nausea , visual disturbances , decreased level of consciousness , nerve palsies and seizures . low gcs may be due to post - ictal state but could also be a sign of intracranial haemorrhage as a result of eclampsia or complications of dural puncture.[46 ] seizures may cause proteinuria , transient increase in blood pressure , pyrexia and a raised wcc , but these signs are also suggestive of eclampsia or central nervous system infection . treatments used for post - dural puncture headache ( pdph ) could also cause seizures [ table 1 ] . hence , intracranial complications such as bleeding certainly need to be excluded before performing an epidural blood patch . it is unfortunate that in patients with dural puncture and seizures , a lumbar puncture is necessary to exclude meningitis or a subarachnoid haemorrhage not visible on ct scan as this obviously could worsen the pdph . causes of post - partum seizures an accurate diagnosis is important as many of these conditions are life - threatening and require specific treatment . a thorough history , clinical examination , routine blood tests and urinalysis will be required in all cases , but we think that one can not be certain of the diagnosis until a lumbar puncture , ct scan and possibly a mr venous angiogram have been performed , as we did in this case . we propose that in this case , headache and seizures were caused by dural puncture . epidural blood patch resulted in immediate relief of symptoms , but it was necessary to exclude other pathology first . we would like to remind the anaesthetic community of the association between dural puncture and seizures and stress that a complete workup is required before attributing seizures to this . this report provides the clinician an insight to approach a patient with post - partum seizures and envisages to consider a broader picture of the clinical situation rather than to just blame the epidural as the cause . also , a multidisciplinary team management including anaesthetists , neurologists , obstetricians and radiologists is invaluable for safe patient care .
we discuss the differential diagnosis and management of early post - partum seizures and headache following a presumed dural puncture in a 20-year - old female . 
 she initially presented with generalised tonic 
 clonic seizures preceded by nausea and headache on the fourth post - partum day along with a decreased glasgow coma scale ( 8/15 ) . although clinical and laboratory examination including lumbar puncture , computerized tomography and magnetic resonance imaging were normal , a persistent headache was the only symptom . 
 this headache improved dramatically after an epidural blood patch on the eighth post - partum day . 
 the following discussion emphasises that various causes of post - partum seizures and headache should be considered before attributing it to dural puncture alone .