The patient presented with severe neck pain and occipital headache, which was significantly different from her typical migraine episodes, worse on sitting up than in supine position, occurring shortly after vaginal delivery, following lumbar epidural anesthesia.  CT scan of the head and spine revealed extensive pneumorrhachis and pneumocephalus, likely from inadvertent dural puncture.

Subsequent brain MRI revealed engorgement of dural venous sinuses and pachymeningeal enhancement, suggesting intracranial hypotension. The patient received blood patches, resulting in symptom improvement. The clinical course was further complicated by postpartum pre-eclampsia, necessitating magnesium sulfate.

Five days later, the patient presented with right facial droop and worsening headaches. Repeat brain MRI showed partial resolution of pneumocephalus and persistent pachymeningeal thickening. Antiviral and steroid treatment were initiated for suspected idiopathic Bell's palsy.

This unusual case underscores the importance of considering multiple potential causes of postpartum headaches. In this case, headache could have been related to intracranial hypotension and preeclampsia in addition to the rare occurrence of pneumorrhachis and pneumocephalus. It emphasizes the need for a comprehensive, multidisciplinary approach to diagnosis and treatment in the postpartum period, where a constellation of factors can contribute to complex clinical presentations. This case serves to raise awareness among neurologists, anesthesiologists and obstetricians about the varied causes of postpartum headache and their management.