Basics
Description
- Headaches account for 1/3 of neurologic problems in pregnancy, with migraine and tension headaches being the commonest causes.
- Certain causes of headache, otherwise considered rare in nonpregnant population, deserve special consideration in pregnancy.
Epidemiology
Prevalence
- Headache as a symptom is reported by >80% women of childbearing age.
- During pregnancy, headaches are most common in the first trimester.
- Migraine headaches
- Tend to improve in pregnancy in most patients
- However, up to 25% of patients will experience no improvement in pregnancy.
- Some women may experience the first attack of migraine during pregnancy.
- May recur or occur for the first time in the postpartum period in up to 40% women.
Risk Factors
Several factors may contribute towards increased tendency for headaches in pregnancy:
- Sleep deprivation
- Stress
- Hormonal changes
- Discontinuation of caffeine
General Prevention
- Reduce sleep deprivation
- Stress reduction
- Dietary modification (see "Diet " )
- Avoidance of other known triggers
Pathophysiology
- Migraine headaches have been linked to falls in estrogen levels, which may explain in part their improvement in pregnancy and worsening postpartum.
- Tension headaches are thought to be due to muscle contraction and are often related to periods of stress.
Diagnosis
Certain features in a patient with headache warrant further work-up:
- Systemic signs (fever, weight loss, history of HIV or malignancy)
- Neurologic symptoms or signs
- Onset: Sudden, abrupt, new onset
- Older patient: New onset progressive headache
- Previous headache history: Change in frequency, severity, or clinical features
History
Certain clues in history may suggest specific causes.
- Tension
- Daily headaches
- Related to stress
- Squeezing in nature
- Worse in afternoon
- Migraine
- Severe
- Throbbing
- Unilateral
- Worse with activity
- Sensitivity to light/sound
- Nausea, vomiting
- Preeclampsia
- >20 weeks gestation
- Associated visual disturbance
- Nausea, vomiting
- Epigastric pain
- Pseudotumor cerebri
- Retro-orbital headache
- Worse when supine
- Obesity, particularly rapid weight gain
- Diplopia
- Space-occupying lesion
- Focal headache
- Associated with seizures
- Visual field defects (pituitary tumors)
- Infectious causes
- Fever
- Photophobia
- Vomiting
- Neck stiffness (meningitis)
- Sinus tenderness, facial pain (sinusitis)
- Non-CNS causes
- Hyperthyroidism
- Sleep apnea
- Subarachnoid hemorrhage
- Sudden, severe headache
- Neurologic signs
- Collapse
- Sentinel headache
- Cerebral vein thrombosis (CVT)
- Postpartum period
- After miscarriage
- History of thrombophilia
- Subacute or sudden onset headache
- 30 " 60% have neurologic signs, may be transient
Physical Exam
- Physical exam in most patients with tension, migraine, or cluster headache is normal.
- Following features may be present with infection, tumor, bleed, thrombosis, or preeclampsia:
- Fever
- Neck stiffness
- Neurologic signs
- Papilledema
- Epigastric/right upper quadrant tenderness (in preeclampsia)
- Hypertension (preeclampsia, CNS event)
- Nasal mucosal and sinus congestion is common in pregnancy.
- Caution as over-diagnoses of chronic sinusitis common
Tests
Lab
- Preeclampsia
- Elevated creatinine (normal for pregnancy ≤0.8 mg/dL)
- Elevated liver enzymes
- Thrombocytopenia
- Hemoconcentration
- Elevated uric acid (normal for pregnancy ≤4.5 mg/dL)
- Proteinuria
- Gold standard is 24-hour urine collection.
- Accuracy of protein:creatinine ratio in pregnancy has not been established but may be helpful if followed serially in pregnant patients with chronic proteinuria.
- Thyroid function tests, urine toxicology screen, and sleep studies can be ordered as indicated by history and physical.
Imaging
Both CT (with and without contrast) and MRI are safe to perform in pregnancy.
- Indications for imaging in pregnancy are same as in nonpregnant patients.
- Avoid use of gadolinium unless the benefit of the additional information gained outweighs the unknown risk of its use.
- MRV is the test of choice for suspected CVT.
- MRA is useful to identify aneurysms and arteriovenous malformations (AVM).
Surgery
- Lumbar puncture indicated for suspected
- Meningitis
- Aseptic meningitis picture possible in CVT
- Pregnant women are at increased risk of listeriosis which is associated with fetal demise.
- Intracerebral bleed
- Pseudotumor cerebri
- Visual field testing may be indicated in:
- Pituitary tumors
- Pseudotumor cerebri
Differential Diagnosis
- Differential in pregnancy is essentially same as nonpregnant.
- Particular consideration should be given to:
- Preeclampsia
- AVM/aneurysms
- Typically asymptomatic in nonpregnant women
- However, with expansion of blood volume during pregnancy, may increase in size and cause headaches.
- The risk for initial rupture of AVM is highest in the second trimester and during labor and delivery.
- The risk for rupture of aneurysm increases with each trimester of pregnancy and decreases in the postpartum period.
- CVT and stroke
Treatment
Medication
- Tension headaches in pregnancy are best managed with acetaminophen, heat, massage, and rest.
- Migraine headache
- Abortive therapy (1,2)[A], (3)[B]:
- Combination of acetaminophen 1 g, antiemetic, and a caffeinated beverage
- Antiemetics which are safe in pregnancy: Metoclopramide, compazine, promethazine
- Magnesium sulfate 1 g IV is useful for acute treatment of migraine in nonpregnant patients and can be safely used in pregnancy.
- Avoid triptans, NSAIDs
- Narcotics are safe in pregnancy.
- Prophylaxis (1,2)[A], (3)[B]:
- Amitriptyline, nortriptyline, beta-blockers such as metoprolol or pindolol, low-dose aspirin (81 mg), magnesium oxide (400 " 800 mg)
- Avoid propranolol and atenolol because of association with intrauterine growth restriction
- Preeclampsia
- If suspected as cause of headache, delivery (either by induction or cesarean section) may be appropriate.
- Magnesium sulfate IV may be added for seizure prophylaxis.
- CVT
- Warrants full anticoagulation for at least 6 " 12 months
- During pregnancy, heparin (unfractionated or low molecular weight) is the only option.
- Coumadin is contraindicated in pregnancy.
Several medications can be used for treatment of headaches. Use in pregnancy of some medications based upon risk is described below.
First Line
Medications with acceptable risk (safest) (1,2)[A], (3)[B]:
- Acetaminophen, metoclopramide, prochlorperazine, promethazine, magnesium, codeine, meperidine, morphine, oxycodone, methadone, prednisone, amitriptyline, beta-blockers (see above for exceptions)
- Avoid use of narcotics for prolonged periods and at high doses at term
Second Line
Moderate risk (less safety data available) (1,2)[A], (3)[B]:
- Calcium channel blockers
- NSAIDs
- Occasional use in first 2 trimesters may be safe but contraindicated in third trimester.
- SSRIs
- Acetaminophen with butalbital
High or unknown risk (avoid use in pregnancy)
- Aspirin 325 mg dose
- ASA 81 mg daily has been shown to be safe in pregnancy.
- Ergotamine
- Triptans
- Valproic acid
- Phenobarbital
- Although newer antiepileptic medications are FDA category C, the lack of adequate safety data precludes their use in pregnancy for this indication.
Additional Treatment
General Measures
- Reassurance that migraine and tension headaches are benign and do not have adverse effects on fetus often helpful.
- Stress management
- Improve sleep deprivation if possible
Issues for Referral
Consider neurology referral for:
- Atypical headache or uncertain diagnosis
- Associated neurologic signs/symptoms
- Treatment failure
Complementary and Alternative Medicine
- Magnesium 400 " 800 mg daily has shown some benefit as migraine prophylaxis and is safe in pregnancy (2,4)[B].
- No evidence exists regarding safety of herbal remedies such as feverfew or butterbur in pregnancy.
- Vitamin supplements (riboflavin, coenzyme Q10, and hydroxocobalamin) have not been studied in pregnancy.
- Acupuncture, chiropractic, and massage may be helpful (see "Headache " chapter).
Surgery
Surgical management is appropriate if indicated for treatment of AVM, aneurysm, or intracerebral tumors or bleeds.
In-Patient Considerations
Admission Criteria
- Similar to nonpregnant
- Admission for suspected preeclampsia is appropriate
Ongoing Care
Diet
- Certain foods, such as nuts, chocolate, and cheeses, may trigger migraine headaches and are best avoided.
- Caffeine withdrawal: 150 " 300 mg of caffeine intake per day is acceptable in pregnancy.
- One 8-oz cup of coffee contains approximately 100 " 200 mg caffeine
Prognosis
- Prognosis for successful pregnancy outcome is excellent with most common causes of headache.
- Preeclampsia, listeriosis, massive intracranial bleed, or stroke may be associated with poor fetal outcome.
References
1Contag SA, Bushnell C. Contemporary management of migrainous disorders in pregnancy. Curr Opin Obstet Gynecol. 2010;22(6):437 " 445. [View Abstract]2Evers S, Afra J, Frese A. EFNS guideline on the drug treatment of migraine " revised report of an EFNS task force. Eur J Neurol. 2009;16(9):968 " 981. [View Abstract]3Torelli P, Allais G, Manzoni GC. Clinical review of headache in pregnancy. Neurol Sci. 2010;31(Suppl 1):S55 " S58. [View Abstract]4Airola G, Allais G, Castagnoli Gabellari I. Non-pharmacological management of migraine during pregnancy. Neurol Sci. 2010;31(Suppl 1):S63 " S65. [View Abstract]
Additional Reading
1Klein AM, Loder E. Postpartum headache. Int J Obstet Anesth. 2010;19(4):422 " 430. [View Abstract]2Lee R, Rosene-Montella K, Barbour L Medical care of the pregnant patient. Philadelphia, PA: American College of Physicians, 2008.3Loder E, Martin VT. Headache: ACP key diseases series. Philadelphia, PA: American College of Physicians, 2004.
Codes
ICD9
- 307.81 Tension headache
- 346.1 Common migraine
- 784.0 Headache
- 339.00 Cluster headache syndrome, unspecified
- V12.3 Personal history of diseases of blood and blood-forming organs
ICD10
- G43.009 Migraine w/o aura, not intractable, w/o status migrainosus
- G44.209 Tension-type headache, unspecified, not intractable
- R51 Headache
- G44.009 Cluster headache syndrome, unspecified, not intractable
- Z86.2 Prsnl history of dis of the bld/bld-form org/immun mechnsm
SNOMED
- 25064002 headache (finding
- 398057008 tension-type headache (disorder)
- 56097005 migraine without aura (disorder)
- 103008008 postpartum headache (finding)
- 193031009 cluster headache syndrome (disorder)
- 234467004 thrombophilia (disorder)
- 441882000 history of thrombophilia (situation)
Clinical Pearls
- Headaches are common in pregnancy.
- Common etiologies (migraine, tension) prevail
- Benign conditions are often undertreated.
- Certain unusual causes of headache deserve particular consideration in pregnancy and postpartum period.
- Consider preeclampsia in the differential diagnosis after 20 weeks gestation
- CT and MRI are safe to perform in pregnancy when indicated.