Differential Diagnosis of Headache in Pregnancy
| Diagnosis | Key features | Management |
|---|---|---|
| Meningitis | As in non-pregnant population | Bloods: FBC, CRP, blood cultures Urgent antibiotics Antivirals, that is acyclovir if suspicion of viral encephalitis |
| Subarachnoid haemorrhage | As in non-pregnant population | CT head Lumbar puncture to look for xanthochromia if CT head negative |
| Space occupying lesion | As in non-pregnant population | Depends on lesion and the presentation |
| Benign intracranial hypertension | Papilloedema and raised intracranial pressure (ICP) in the absence of another explanation This can present for the first time in pregnancy | Imaging to exclude another cause for raised intracranial pressure Lumbar puncture to measure pressure and can be repeated for symptom relief Regular assessment of visual acuity and fields To reduce ICP, thiazides and acetazolamide (avoid 1st trimester) |
| Migraine | Features as in non-pregnant population (see Chapter 15) Classical migraine may improve in pregnancy Can be different in nature to the migraines experienced when not pregnant, that is, aura without headache, or new aura | Analgesia (not NSAIDs) Triptans can be used sporadically if they are the only successful treatment for an acute event Prophylaxis: low dose aspirin or propranolol Avoid ergotamine, pizotifen, valproate, gabapentin and topiramate |
| Pre-eclampsia or hypertension | Hypertension and proteinuria Other symptoms: visual disturbance, epigastric/right upper quadrant pain MRI may show posterior reversible encephalopathy syndrome (PRES) | Bloods: platelet count, renal and liver function IV magnesium sulphate if severe disease present (Table 32.8) Delivery depends on gestation and severity |
| Intracranial haemorrhage | Sudden onset headache Risk factors include pre-eclampsia or hypertension, trauma, vascular or coagulation abnormalities | Bloods: FBC and coagulation Imaging – CT or MRI Management is neurosurgical and depends on nature of the haemorrhage and underlying aetiology |
| Cerebral venous thrombosis | Is associated with pregnancy and can occur in any trimester or post-partum May be associated with vomiting, photophobia, reduced conscious level, seizures or signs of raised intracranial pressure On examination focal signs may be present; a low grade fever is also common | Bloods may show a raised white cell count Imaging – CT or MRI, and venography Thrombophilia screen LMWH or UFH can be used safely in pregnancy and during breastfeeding |
| Drug-related headache | May be caused by regular analgesic use, vasodilators such as calcium antagonists (e.g. nifedipine used in treatment of hypertension in pregnancy) | Review use of the likely causative drug |
| Post-dural puncture headache | Headache occurs within 1–7 days of dural puncture Usually postural and is relieved on lying flat Other symptoms: neck stiffness, visual symptoms or seizures (rare) | Conservative management – analgesia, bed rest, maintain good hydration or a blood patch |