Headache during pregnancy

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

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

  • 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

  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.