Headache during pregnancy: Difference between revisions

No edit summary
Line 64: Line 64:
*Breastfeeding contraindicated - dihydroergotamine, ergotamine
*Breastfeeding contraindicated - dihydroergotamine, ergotamine


==Sources==
==References==
<references/>
<references/>



Revision as of 03:17, 5 August 2015

Background

  • Must r/o preeclampsia/eclampsia in > 20 wks gestation
  • Most pregnant women with primary HAs have dx before pregnancy
  • 10% pregnant women will have new presentation during gestation, of which:
    • 1/3 have migraine
    • 1/3 have PET/eclampsia HA

Clinical Features

  • Headache while pregnant

Differential Diagnosis

Diagnosis

  • Clinical suspicion guides labs and imaging
  • LP if increased ICP or infection suspected
  • MRI/MRA/MRV preferred to CT head, though radiation scatter minimal
  • Avoid gadolinium; Iodine contrast may be safe

Management

  • Initial - acetaminophen 1000 mg PO, and may add:
  • Other options
  • 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

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.