Headache is a common complaint in pregnancy.
Although most of these headaches are due to benign causes, it is imperative that obstetric providers perform a thorough history and physical examination to identify those headaches that warrant further workup (Table 17-1).
In the presence of concerning signs or symptoms, neurology consultation and diagnostic workup should be performed.
Lumbar puncture (LP), magnetic resonance imaging (MRI), and head computed tomography (CT) can be considered for a headache with concerning features.
MRI poses no radiation exposure risks to the fetus and is the imaging of choice for pregnant patients. However, MRI is expensive and often not readily available.
Head CT is the imaging of choice for nonpregnant patients because it is less expensive and more readily available in most settings. Although head CT does expose the fetus to some radiation, it is approximately 0.05 rad. This is geometrically below the 5 rad exposure associated with risk of fetal anomalies or pregnancy loss. As such, the diagnostic benefit of a head CT, as with any clinical test, should be weighed against its risks.
An LP is not contraindicated in pregnancy and should be used if clinically indicated.
Any headache beyond 20 weeks' gestation and up to 12 weeks' postpartum, especially if not relieved by pain medications, should include evaluation for preeclampsia.
Postdural puncture headache should be considered in postpartum patients particularly if they experience postural headaches (a headache that worsens upon sitting or standing and that improves when the patient lays flat on her back). Although acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and caffeine are often effective in controlling the pain, anesthesia consultation for blood patching should be considered in patients who are refractory to conservative treatments.
Although many chronic migraine sufferers report improved symptoms during pregnancy, it remains a common cause of headache in pregnancy.
Approximately 2% of women have their first migraine while pregnant.
Typical migraine symptoms include unilateral throbbing headache episodes, which last between 4 and 72 hours and are associated with nausea, vomiting, phonophobia, and photophobia. Some patients also experience a phenomenon known as an aura. It is defined as the development of visual symptoms (ie, a scintillating scotoma, partial loss of visual field) lasting 20 minutes followed by a headache.
Imaging: Noncontrast brain MRI can be used to rule out other causes of headache if alarm symptoms or signs are present.
Treatment: Many of the same pharmacologic and nonpharmacologic treatments that are useful outside of pregnancy are also used during pregnancy. Limit therapy to a maximum of 2 to 3 days per week to avoid a medication-overuse headache.
Behavioral and nonpharmacologic therapy: Avoid alcohol and tobacco use. Maintain a regular meal and sleep pattern. Encourage regular exercise and adequate hydration. Other options are relaxation, biofeedback, and acupuncture.
Acute symptom management: Treatment of acute migraines can involve a variety of medications (Table 17-2).
Breastfeeding: Women who breastfeed are less likely to have migraine headache recurrence in the postpartum period. Acetaminophen, NSAIDs, metoclopramide, triptans, and opioids can be used. Avoid high-dose aspirin. Ergots are contraindicated.
Prophylaxis therapy: β-Blockers (metoprolol, propranolol, and atenolol), calcium channel blockers (nifedipine), antiepileptics (gabapentin), and antiplatelets (aspirin in doses ≤150 mg/d) can be used in pregnancy. Selective serotonin reuptake inhibitors (citalopram, escitalopram, fluoxetine, sertraline), serotonin-norepinephrine reuptake inhibitors (venlafaxine), and tricyclics (low-dose amitriptyline and nortriptyline) can be used in patients with comorbid depression.
Tension headaches are the most common type of headache.
Patients describe tightness or tension in their head often with radiation to the neck. There are no associated symptoms or disability.
The frequency of tension headaches is typically not altered by pregnancy.
Treatment: Behavioral treatment includes avoiding skipping meals, maintaining a regular exercise and sleep pattern, maintaining adequate hydration, and avoiding alcohol and tobacco use. Nonpharmacologic therapies such as heat, massage, relaxation, physical therapy, and acupuncture are often helpful. Pharmacologic treatment with acetaminophen is the first-line therapy. The NSAIDs can be used in the second trimester, but chronic use should be avoided. Muscle relaxants can often be a useful adjunct.
Cluster headaches are recurrent, unilateral headaches that are accompanied by autonomic symptoms such as nasal stuffiness, tearing, facial swelling, or eyelid edema. They can last up to 2 hours and occur in clusters typically lasting 6 to 8 weeks.
Acute treatment: Oxygen (100% at 10-15 L/min for 10-15 min via nonrebreather face mask) at the onset of attack is first-line therapy. Subcutaneous or intranasal triptans and intranasal lidocaine can also be useful adjunct therapies.
Prophylaxis during pregnancy and breastfeeding includes verapamil and prednisone/prednisolone.
Cerebral venous thrombosis is most common in the postpartum period and in women with thrombophilia.
It is characterized by progressive, diffuse, unremitting headache. Accompanied by seizures, focal neurologic signs, and funduscopy with signs of elevated intracranial pressure.
Imaging: Noncontrast CT is often unrevealing. Noncontrast brain MRI scan and magnetic resonance venogram show nonarterial territorial infarct.
Treatment: Anticoagulation with intravenous (IV) heparin or low-molecular-weight heparin is recommended during pregnancy. Low-molecular-weight heparin or warfarin should be continued for at least 6 weeks postpartum. Consider thrombophilia workup, especially when there are prior thrombosis episodes or a family history of thrombophilia.
Pseudotumor cerebri is characterized by diffuse, nonthrobbing, daily headache aggravated by coughing and straining. It can be associated with papilledema, visual field defect, or sixth nerve palsy.
Imaging: Rule out intracranial mass or cerebral venous thrombosis with a noncontrast head CT and MRI/MR venography, respectively.
Diagnosis: Diagnosis includes LP with increased cerebrospinal fluid pressure with normal cerebrospinal fluid chemistry. Serial LPs are also therapeutic.
Treatment: The mainstay of treatment is to decrease intracranial pressure. Consider acetazolamide and controlled weight gain during pregnancy. Symptomatic management for headaches may be necessary (see Table 17-2).