Headaches & Pregnancy

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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