Headaches & Pregnancy
/What are the different types of headaches?
Migraine
Episodic disorder that is usually manifested as unilateral headaches, sometimes associated with nausea or light/sound sensitivity
Common disorder that affects 12-15% of general population
Can occur over several hours to several days
Different phases of migraine:
Prodrome - can occur in up to 77% of people, usually can be symptoms like yawning, depression, irritability, food cravings, neck stiffness, etc
Aura - 25% of people will experience an aura that is gradual, sometimes visual (bright lines), auditory (tinnitus, etc), somatosensory, motor, or even can be smell
Headache - usually unilateral, tends to be throbbing
Postdrome - sometimes can happen. Head movement may cause pain in location of the previous headache
Triggers - can be different for different people. Common triggers are things like menstrual cycle, stress, etc
Tension headache
Usually moderate headaches with bilateral, non-throbbing quality
Often described as “pressure,” sometimes may feel like a band around the head (headband area)
Precipitated usually by stress
Cluster headache
Severe headache that can be accompanied by autonomic symptom, come in “clusters”
It is a type of trigeminal autonomic cephalagia (TACs)
Usually characterized by severe orbital, supraorbital, or temporal pain, and also with autonomic features. Always unilateral.
Different from migraines because these patients usually prefer to move around or pace, can be restless (people with migraines want to lie down in a dark room)
Autonomic symptoms: ptosis, miosis, tearing, rhinorrhea, nasal congestion on the same side as the pain
Secondary headaches
Have an underlying cause (i..e., headache is a symptom of the problem) - this is something we may need to be worried about.
More benign: sinusitis, URI, idiopathic intracranial hypertension (IIH)
More serious: tumor, bleeding, meningitis.
Evaluating a Headache
History
Your usual history, but be sure to ask about age of onset of headaches (has this been going on for 20 years, or just today?), presence of aura/prodrome, frequency and intensity
# of headaches/month, site of headache/other symptoms associated
Current meds
Changes in vision, association with trauma, changes in work/lifestyle, timing around menstrual cycle
Physical
Blood pressure and pulse - always in pregnancy — worry about preeclampsia!
Palpation of neck, head, and shoulder
Full neuro exam
Labs and Imaging
CT or MRI are common modalities
Consider imaging if danger signs are present (i.e., abnormal neuro exam)
Also consider lumbar puncture if there is concern for infection
When should I be worried about a headache?
Low Risk Features
Age <50
Features that are typical of primary headaches (see above)
History of similar headaches, no change in usual headache or new symptoms
No abnormal neurologic symptoms
Higher Risk Characteristics
Fever, abrupt onset, older age, neurologic deficit (including altered mental status), history of tumors, papilledema
Change in previous pattern, headache with positional change, post-trauma, painful eyes (or change in vision!)
And of course, pregnancy!
Reason for emergency eval: thunderclap headache, Horner syndrome or other neurologic deficit, concern for meningitis or encephalitis, papilledema, possible carbon monoxide exposure.
What are typical headache treatments?
Non-Pregnant
Migraine Headache
Analgesics like NSAIDs, Tylenol; treating earlier in the course is more effective
If unresponsive, can consider triptans or ergots
If still severe, consider ketorolac and a dopamine receptor blocker (ie. prochorperazine and metoclopramide)
Some patients may need to be on medications like triptans or beta blockers to prevent headaches
Preventive first line agents are propranolol, amitriptyline, topiramate
Tension Headache
Usually rest, hydration
NSAIDs, acetaminophen
Then consider caffeine, metoclopramide, diphenydramine, etc.
Cluster Headaches
Oxygen! Try it first if available - 100% oxygen inhalation
If not available, then subcutaneous sumatriptan (3mg-6mg); can also use intranasal if subq not available
Administer the intranasal sumatriptan to the contralateral side because patients with cluster headaches and other trigeminal autonomic cephalalgias have rhinorrhea or nasal congestion that is on same side as pain.
Prevention: verapamil… agent of choice for initial preventative therapy. Can also start with a short course of prednisone
This is because we know that cluster headaches come in… you guessed it! Clusters!
In Pregnancy
May need to avoid NSAIDs in certain trimesters
Start with Tylenol (650-1000mg), then can ad metoclopramide 10 mg
Can also try combination like butalbital-acetaminophen-caffeine
Other options are things like diphenhydramine (benadryl), or prochlorperazine, as some types of headaches may be associated with n/v and can help with this
Consider fluids if someone is dehydrated (again, n/v in pregnancy)
Magnesium sulfate or magnesium oxide sometimes can help. If someone has frequent headaches, there is some data that magnesium can prevent headaches
If still bad, consider NSAID, but usually should not be used after 32 weeks to prevent closure of the PDA; usually a one time dose is ok
Third line = opioids because they can be addicting and can worsen other issues of pregnancy like nausea/vomiting/constipation
Triptans - if not responding to anything else, can consider triptans. Most studies showing exposure in pregnancy have been reassuring (most studies are with sumatriptan)
Long term triptan use in pregnancy - discuss individually with patient
Limited data, but from registries, no increased risk of major malformation
If patients can use other meds, try those first, but if refractory and need sumatriptan, ok to use
Other things to consider if refractory:
Glucocorticoids, peripheral nerve blocks
Call your neurology colleagues!
Meds to avoid
Ergotamine - do not use because can cause tetanic uterine contractions