Headache during pregnancy: Difference between revisions

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==Background==
==Background==
*Must r/o preeclampsia/eclampsia in > 20 wks gestation
*Most pregnant women with primary headaches have diagnosis before pregnancy
*Most pregnant women with primary HAs have dx before pregnancy
*10% of pregnant women will have new onset headache during gestation
*10% pregnant women will have new presentation during gestation, of which:
**1/3 due to migraine
**1/3 have migraine
**1/3 due to pre-eclamptic toxemia (PET)/eclampsia
**1/3 have PET/eclampsia HA


==DDx==
==Clinical Features==
*Consider usual differential for HAs
*[[Headache]] while pregnant
*May need pre-eclampsia/eclampsia r/o
 
*New onset of severe HA in no hx of migraines, keep high suspicion of<ref>Armon C et al. Neurologic Disease and Pregnancy. Updated Feb 24, 2015. http://emedicine.medscape.com/article/1149405-overview#a4</ref>:
==Differential Diagnosis==
**ICH
*Consider usual differential for [[headache]]s
*Also consider [[preeclampsia]]/[[eclampsia]] (especially if >20 weeks gestation)
*New onset of severe headache in no history of migraines → maintain high suspicion of<ref>Armon C et al. Neurologic Disease and Pregnancy. Updated Feb 24, 2015. http://emedicine.medscape.com/article/1149405-overview#a4</ref>:
**[[Intracranial hemorrhage (main)|ICH]]
**[[Temporal arteritis]]
**[[Temporal arteritis]]
**[[Vertebral and carotid artery dissection]]
**[[Vertebral and carotid artery dissection]]
**[[Cerebral venous thrombosis]]
**[[Cerebral venous thrombosis]]
**[[Cavernous sinus thrombosis]]
***[[Cavernous sinus thrombosis]]
**[[Meningitis]]
**[[Meningitis]]
**Reversible posterior leukoencephalopathy
**[[Posterior reversible encephalopathy syndrome]]
**Pituitary apoplexy
**[[Sheehan's syndrome|Pituitary apoplexy]] (Sheehan syndrome)


==Workup==
==Evaluation==
*Clinical suspicion guides labs and imaging
*Clinical suspicion guides labs and imaging
*LP if increased ICP or infection suspected
*[[head CT|CT]] ± [[Lumbar puncture]] if increased ICP or infection suspected
*MRI/MRA/MRV preferred to CT head, though radiation scatter minimal
*[[brain MRI|MRI]] preferred to CT (though radiation scatter minimal)
*Avoid gadolinium; Iodine contrast may be safe
**Avoid gadolinium


==Management==
==Management==
*Initial - acetaminophen 1000 mg PO, and may add:
*Initial - [[acetaminophen]] 1000mg PO, and may add:
**Metoclopramide 10 mg IM/IV or PO
**[[Metoclopramide]] 10mg IM/IV or PO
**Codeine 30 mg PO
*Other options
*Sumatriptan 100 mg PO or 4-6 mg SQ
**[[Sumatriptan]] 100mg PO or 4-6mg SQ
*Diphenhydramine 25 - 50 mg PO
**[[Diphenhydramine]] 25 - 50mg PO
*Promethazine 12.5 - 25 mg PO
**[[Promethazine]] 12.5 - 25mg PO
*Ondansetron 4 - 8 mg IV for severe n/v
**[[Ondansetron]] 4 - 8mg IV for severe nausea/vomiting
***Ensure no [[hypokalemia]], [[hypomagnesemia]], [[hypocalcemia]] for prolonged QT
***Consider recent conflicting studies on risk of birth defects<ref>Pasternak B et al. Ondansetron in Pregnancy and Risk of Adverse Fetal Outcomes. N Engl J Med 2013; 368:814-823.</ref><ref>Koren G. Treating morning sickness in the United States – changes in prescribing are needed. American Journal of Obstetrics & Gynecology, Volume 211. December 2014, Pages 602-606.</ref>
*Refractory migraine option 1:
*Refractory migraine option 1:
**IV hydration
**IV hydration
**Pre-Tx diphenhydramine 25 mg for EPS
**Pre-treatment [[diphenhydramine]] 25mg for EPS
**Antiemetic
**[[Antiemetics]]
**IV opioid
**[[Codeine]] 30mg PO
**IV [[opioid]]
*Refractory migraine option 2<ref> Wang SJ et al. Droperidol treatment of status migrainosus and refractory migraine. Headache. 1997;37(6):377.</ref>:
*Refractory migraine option 2<ref> Wang SJ et al. Droperidol treatment of status migrainosus and refractory migraine. Headache. 1997;37(6):377.</ref>:
**Triptan
**[[sumatriptan|Triptan]]
**Droperidol 2.5 mg IV q30 min up to 3 doses
**[[Droperidol]] 2.5mg IV q30 min up to 3 doses
*Consider peripheral nerve blocks
*Consider peripheral nerve blocks
*Consider steroids in intractable migraines
*Consider [[steroids]] in intractable migraines
**Prednisone 20 mg PO QID x2 days or methylprednisolone 4 mg PO, 21 tablets over 6 days
**[[Prednisone]] 20mg PO QID x2 days or methylprednisolone 4mg PO, 21 tablets over 6 days
**Avoid dexamethasone and betamethasone
**Avoid [[dexamethasone]] and betamethasone
**Avoid steroids in 1st trimester
**Avoid steroids in 1st trimester
*No benefit of IV magnesium in meta-analysis<ref>Choi H, Parmar N. The use of intravenous magnesium sulphate for acute migraine: meta-analysis of randomized controlled trials. Eur J Emerg Med. 2014 Feb;21(1):2-9.</ref>
*No benefit of IV [[magnesium]] in meta-analysis<ref>Choi H, Parmar N. The use of intravenous magnesium sulphate for acute migraine: meta-analysis of randomized controlled trials. Eur J Emerg Med. 2014 Feb;21(1):2-9.</ref>


==Pregnancy Categories of Common Medications==
===[[drug pregnancy categories|Pregnancy Categories]] of Common Medications===
*Class B - acetaminophen, caffeine, metoclopramide, promethazine
*Class B - [[acetaminophen]], [[caffeine]], [[metoclopramide]], [[promethazine]]
*Class C - prochlorperazine (not enough human data but studies suggest safety), prednisolone, droperidol, ketorolac, 5-HT1 agonists (triptans), gabapentin, topiramate, CCBs, TCAs
*Class C - [[prochlorperazine]] (not enough human data but studies suggest safety), [[prednisolone]], [[droperidol]], [[ketorolac]], 5-HT1 agonists (triptans), [[gabapentin]], [[topiramate]], [[calcium-channel blockers]], [[TCAs]]
*Class D - valproate
*Class D - [[valproate]]
*Class D in 3rd trimester - aspirin, ibuprofen, naproxen
*Class D in 3rd trimester - [[aspirin]], [[ibuprofen]], [[naproxen]]
*Class D at term or prolonged use - codeine, morphine, BBs
*Class D at term or prolonged use - [[codeine]], [[morphine]], [[beta-blockers]]
*Class X - dihydroergotamine, ergotamine
*Class X - dihydroergotamine, ergotamine
*Breastfeeding compatible - aspirin, caffeine, ibuprofen, naproxen, codeine, morphine, prednisolone, triptans (likely compatible), BBs
*Breastfeeding compatible - aspirin, caffeine, ibuprofen, naproxen, codeine, morphine, prednisolone, triptans (likely compatible), beta-blockers
*Breastfeeding contraindicated - dihydroergotamine, ergotamine
*Breastfeeding contraindicated - dihydroergotamine, ergotamine


==Sources==
==Disposition==
 
 
==See Also==
*[[Pregnancy (main)]]
*[[Headache]]
 
==References==
<references/>
<references/>
[[Category:OBGYN]]
[[Category:Neurology]]
[[Category:Symptoms]]

Latest revision as of 02:40, 11 March 2023

Background

  • Most pregnant women with primary headaches have diagnosis before pregnancy
  • 10% of pregnant women will have new onset headache during gestation
    • 1/3 due to migraine
    • 1/3 due to pre-eclamptic toxemia (PET)/eclampsia

Clinical Features

Differential Diagnosis

Evaluation

  • Clinical suspicion guides labs and imaging
  • CT ± Lumbar puncture if increased ICP or infection suspected
  • MRI preferred to CT (though radiation scatter minimal)
    • Avoid gadolinium

Management

Pregnancy Categories of Common Medications

Disposition

See Also

References

  1. ↑ Armon C et al. Neurologic Disease and Pregnancy. Updated Feb 24, 2015. http://emedicine.medscape.com/article/1149405-overview#a4
  2. ↑ Pasternak B et al. Ondansetron in Pregnancy and Risk of Adverse Fetal Outcomes. N Engl J Med 2013; 368:814-823.
  3. ↑ Koren G. Treating morning sickness in the United States – changes in prescribing are needed. American Journal of Obstetrics & Gynecology, Volume 211. December 2014, Pages 602-606.
  4. ↑ Wang SJ et al. Droperidol treatment of status migrainosus and refractory migraine. Headache. 1997;37(6):377.
  5. ↑ Choi H, Parmar N. The use of intravenous magnesium sulphate for acute migraine: meta-analysis of randomized controlled trials. Eur J Emerg Med. 2014 Feb;21(1):2-9.
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