Headache during pregnancy: Difference between revisions
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==Background== | ==Background== | ||
*Most pregnant women with primary headaches have diagnosis before pregnancy | |||
*Most pregnant women with primary | *10% of pregnant women will have new onset headache during gestation | ||
*10% pregnant women will have new | **1/3 due to migraine | ||
**1/3 | **1/3 due to pre-eclamptic toxemia (PET)/eclampsia | ||
**1/3 | |||
==Clinical Features== | ==Clinical Features== | ||
*Headache while pregnant | *[[Headache]] while pregnant | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*Consider usual differential for | *Consider usual differential for [[headache]]s | ||
* | *Also consider [[preeclampsia]]/[[eclampsia]] (especially if >20 weeks gestation) | ||
*New onset of severe | *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>: | ||
**ICH | **[[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]] | ||
** | **[[Posterior reversible encephalopathy syndrome]] | ||
**Pituitary apoplexy | **[[Sheehan's syndrome|Pituitary apoplexy]] (Sheehan syndrome) | ||
== | ==Evaluation== | ||
*Clinical suspicion guides labs and imaging | *Clinical suspicion guides labs and imaging | ||
*[[ | *[[head CT|CT]] ± [[Lumbar puncture]] if increased ICP or infection suspected | ||
*MRI | *[[brain MRI|MRI]] preferred to CT (though radiation scatter minimal) | ||
*Avoid gadolinium | **Avoid gadolinium | ||
==Management== | ==Management== | ||
*Initial - acetaminophen | *Initial - [[acetaminophen]] 1000mg PO, and may add: | ||
**[[Metoclopramide]] | **[[Metoclopramide]] 10mg IM/IV or PO | ||
*Other options | *Other options | ||
**[[Sumatriptan]] | **[[Sumatriptan]] 100mg PO or 4-6mg SQ | ||
**[[Diphenhydramine]] 25 - | **[[Diphenhydramine]] 25 - 50mg PO | ||
**[[Promethazine]] 12.5 - | **[[Promethazine]] 12.5 - 25mg PO | ||
**[[ | **[[Ondansetron]] 4 - 8mg IV for severe nausea/vomiting | ||
***Ensure no [[hypokalemia]], [[ | ***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> | ***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- | **Pre-treatment [[diphenhydramine]] 25mg for EPS | ||
** | **[[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. | **[[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 | **[[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, | *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, | *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), | *Breastfeeding compatible - aspirin, caffeine, ibuprofen, naproxen, codeine, morphine, prednisolone, triptans (likely compatible), beta-blockers | ||
*Breastfeeding contraindicated - dihydroergotamine, ergotamine | *Breastfeeding contraindicated - dihydroergotamine, ergotamine | ||
==Disposition== | |||
==See Also== | |||
*[[Pregnancy (main)]] | |||
*[[Headache]] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:OBGYN]] | |||
[[Category: | [[Category:Neurology]] | ||
[[Category: | [[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
- Headache while pregnant
Differential Diagnosis
- Consider usual differential for headaches
- Also consider preeclampsia/eclampsia (especially if >20 weeks gestation)
- New onset of severe headache in no history of migraines → maintain high suspicion of[1]:
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
- Initial - acetaminophen 1000mg PO, and may add:
- Metoclopramide 10mg IM/IV or PO
- Other options
- Sumatriptan 100mg PO or 4-6mg SQ
- Diphenhydramine 25 - 50mg PO
- Promethazine 12.5 - 25mg PO
- 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[2][3]
- Refractory migraine option 1:
- IV hydration
- Pre-treatment diphenhydramine 25mg for EPS
- Antiemetics
- Codeine 30mg PO
- IV opioid
- Refractory migraine option 2[4]:
- Triptan
- Droperidol 2.5mg IV q30 min up to 3 doses
- Consider peripheral nerve blocks
- Consider steroids in intractable migraines
- Prednisone 20mg PO QID x2 days or methylprednisolone 4mg PO, 21 tablets over 6 days
- Avoid dexamethasone and betamethasone
- Avoid steroids in 1st trimester
- No benefit of IV magnesium in meta-analysis[5]
Pregnancy Categories of Common Medications
- 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, calcium-channel blockers, TCAs
- Class D - valproate
- Class D in 3rd trimester - aspirin, ibuprofen, naproxen
- Class D at term or prolonged use - codeine, morphine, beta-blockers
- Class X - dihydroergotamine, ergotamine
- Breastfeeding compatible - aspirin, caffeine, ibuprofen, naproxen, codeine, morphine, prednisolone, triptans (likely compatible), beta-blockers
- Breastfeeding contraindicated - dihydroergotamine, ergotamine
Disposition
See Also
References
- ↑ Armon C et al. Neurologic Disease and Pregnancy. Updated Feb 24, 2015. http://emedicine.medscape.com/article/1149405-overview#a4
- ↑ Pasternak B et al. Ondansetron in Pregnancy and Risk of Adverse Fetal Outcomes. N Engl J Med 2013; 368:814-823.
- ↑ 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.
- ↑ Wang SJ et al. Droperidol treatment of status migrainosus and refractory migraine. Headache. 1997;37(6):377.
- ↑ 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.