Headache during pregnancy: Difference between revisions
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==Background== | ==Background== | ||
*Most pregnant women with primary HAs have dx before pregnancy | *Most pregnant women with primary HAs have dx before pregnancy | ||
*10% pregnant women will have new | *10% of pregnant women will have new onset headache during gestation | ||
**1/3 | **1/3 due to migraine | ||
**1/3 | **1/3 due to pre-eclamptic toxemia (PET)/eclampsia | ||
==Clinical Features== | ==Clinical Features== | ||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
*Consider usual differential for HAs | *Consider usual differential for HAs | ||
* | *Also consider pre-eclampsia/eclampsia (esp if >20 WGA) | ||
*New onset of severe HA in no hx of migraines | *New onset of severe HA in no hx 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 | **ICH | ||
**[[Temporal arteritis]] | **[[Temporal arteritis]] | ||
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*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), BBs | ||
*Breastfeeding contraindicated - dihydroergotamine, ergotamine | *Breastfeeding contraindicated - dihydroergotamine, ergotamine | ||
==Disposition== | |||
==See Also== | ==See Also== | ||
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==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:OB/GYN]] | [[Category:OB/GYN]] | ||
[[Category:Neuro]] | [[Category:Neuro]] | ||
Revision as of 05:33, 9 August 2015
Background
- Most pregnant women with primary HAs have dx 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 HAs
- Also consider pre-eclampsia/eclampsia (esp if >20 WGA)
- New onset of severe HA in no hx of migraines → maintain high suspicion of[1]:
- ICH
- Temporal arteritis
- Vertebral and carotid artery dissection
- Cerebral venous thrombosis
- Cavernous sinus thrombosis
- Meningitis
- Reversible posterior leukoencephalopathy
- Pituitary apoplexy
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:
- 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.