Headache during pregnancy: Difference between revisions
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==Management== | ==Management== | ||
*Initial - acetaminophen 1000 mg PO, and may add: | *Initial - [[acetaminophen]] 1000 mg PO, and may add: | ||
**[[Metoclopramide]] 10 mg IM/IV or PO | **[[Metoclopramide]] 10 mg IM/IV or PO | ||
**Codeine 30 mg PO | **[[Codeine]] 30 mg PO | ||
*Other options | *Other options | ||
**[[Sumatriptan]] 100 mg PO or 4-6 mg SQ | **[[Sumatriptan]] 100 mg PO or 4-6 mg SQ | ||
**[[Diphenhydramine]] 25 - 50 mg PO | **[[Diphenhydramine]] 25 - 50 mg PO | ||
**[[Promethazine]] 12.5 - 25 mg PO | **[[Promethazine]] 12.5 - 25 mg PO | ||
**[[ | **[[Ondansetron]] 4 - 8 mg IV for severe n/v | ||
***Ensure no [[hypokalemia]], [[hypomagnesaemia]], [[hypocalcemia]] for prolonged QT | ***Ensure no [[hypokalemia]], [[hypomagnesaemia]], [[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> | ||
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**Pre-Tx diphenhydramine 25 mg for EPS | **Pre-Tx diphenhydramine 25 mg for EPS | ||
**Antiemetic | **Antiemetic | ||
**IV opioid | **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 | **Triptan | ||
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*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]] 20 mg PO QID x2 days or methylprednisolone 4 mg 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> | ||
Revision as of 22:55, 14 July 2016
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 pre-eclampsia/eclampsia (esp if >20 WGA)
- New onset of severe headache in no history of migraines → maintain high suspicion of[1]:
- ICH
- Temporal arteritis
- Vertebral and carotid artery dissection
- Cerebral venous thrombosis
- Meningitis
- Reversible posterior leukoencephalopathy
- Pituitary apoplexy
Diagnosis
- 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 1000 mg PO, and may add:
- Metoclopramide 10 mg IM/IV or PO
- Codeine 30 mg PO
- Other options
- Sumatriptan 100 mg PO or 4-6 mg SQ
- Diphenhydramine 25 - 50 mg PO
- Promethazine 12.5 - 25 mg PO
- Ondansetron 4 - 8 mg IV for severe n/v
- Ensure no hypokalemia, hypomagnesaemia, hypocalcemia for prolonged QT
- Consider recent conflicting studies on risk of birth defects[2][3]
- Refractory migraine option 1:
- IV hydration
- Pre-Tx diphenhydramine 25 mg for EPS
- Antiemetic
- IV opioid
- Refractory migraine option 2[4]:
- Triptan
- Droperidol 2.5 mg IV q30 min up to 3 doses
- Consider peripheral nerve blocks
- Consider steroids in intractable migraines
- Prednisone 20 mg PO QID x2 days or methylprednisolone 4 mg 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, CCBs, TCAs
- Class D - valproate
- Class D in 3rd trimester - aspirin, ibuprofen, naproxen
- Class D at term or prolonged use - codeine, morphine, BBs
- Class X - dihydroergotamine, ergotamine
- Breastfeeding compatible - aspirin, caffeine, ibuprofen, naproxen, codeine, morphine, prednisolone, triptans (likely compatible), BBs
- 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.