Population: Pregnant patients with headache.

Organization

ACOG 2022

Recommendations

Evaluation

–If a patient takes medications for headache prevention, review the necessity, as headache symptoms often decrease during pregnancy. If prevention medications are needed, first-line choices include calcium channel blockers and antihistamines. Several common choices (gabapentin, lisinopril, memantine, etc.) are contraindicated, and many others carry some fetal risk.

–If a headache includes severe pain, rapid onset, high blood pressure, visual changes, neurologic deficits, altered consciousness, vomiting or fever, evaluate urgently for a secondary cause.

–In patients with preeclampsia and headache, consider alternative etiologies if altered level of consciousness, vomiting, or fever.

Management

–For headaches that occur during pregnancy, may treat as before if not contraindicated if features are identical to pre-pregnancy headaches. If not, assess for “red flag” symptoms and consider preeclampsia if ≥20-wk EGA and BP ≥ 140/90 mmHg.

–If headache presents 24–48 h after spinal/epidural anesthesia with occipitofrontal pain and postural features, consult anesthesia for management of spinal headache.

–Treat migraine headaches with acetaminophen 1000 mg initially, or acetaminophen with caffeine (limit caffeine doses to 200 mg/d). Restrict NSAID use to the second trimester.

–Avoid butalbital, ergot alkaloids, and opioids. Use triptans, IV magnesium, and prednisolone with caution.

–For persistent headaches, use metoclopramide 10 mg with or without diphenhydramine 25 mg.

Source

–Obstet Gynecol. 2022;139(5):944.