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

• 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:
  • ICH
  • Temporal arteritis
  • Vertebral and carotid artery dissection
  • Cerebral venous thrombosis
    • Cavernous sinus thrombosis
  • Meningitis
  • Posterior reversible encephalopathy syndrome
  • Pituitary apoplexy (Sheehan syndrome)

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
• Refractory migraine option 1:
  • IV hydration
  • Pre-treatment diphenhydramine 25mg for EPS
  • Antiemetics
  • Codeine 30mg PO
  • IV opioid
• Refractory migraine option 2:
  • 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

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

See Also

• Pregnancy (main)
• Headache