HEADACHE in pregnancy:diagnosis and management

The prevalence of headache in gravid women has been described to be as high as 35%. At least 5% of pregnancies are affected by de novo headache, meaning either new onset or new type of headache.First purpose The first purpose is to distinguish primary headache (when pain is the disease) from a secondary headache (when pain is a symptom of another disease).Three scenarios 1. She suffers from a primary headache and now she presents with her usual headache 2. She does not suffer from a primary headache and she presents with her first severe headache during pregnancy 3. She suffers from a primary headache, but now pain is different in quality, intensity or associated symptoms . The importance of the diagnosis and management of headache in pregnant and postpartum women High rate of secondary headache disorders in this population due to hormonal ,vascular,homeostatic, procedural factors and also treatment decisions must consider both maternal and fetal or new born health.Red flags in the diagnosis of headache 1. systemic symptoms or signs 2. focal neurologic signs or symptoms including papilledema 3. an older age of onset 4. an abrupt onset of severe headache (thunderclap) 5. a pattern change at variance with a preexisting headache disorder 6. precipitation by Valsalva maneuver or exertion, or a postural headache.7. recent evidence suggests that new headache in pregnancy and in the puerperium Evaluate women ≥20 weeks of gestation for preeclampsia Preeclampsia must be considered in every pregnant woman over 20 weeks of gestation with headache. Among pregnant women with no history of a headache and the onset of new or atypical headache who present for evaluation, one-third has preeclampsia.This headache of preeclampsia is similar to those of migraine, except migraine pain is frequently unilateral. A migraine occurring during pregnancy can generally be differentiated from a preeclampsia-related headache by assessment of the patient s blood pressure, urine protein, laboratory studies, gestational age, and whether she reports similar headaches prior to pregnancy.The cause of headache in preeclampsia/eclampsia:The cause of headache in preeclampsia/eclampsia is not known and includeincreased cerebral perfusion pressure, cerebral ischemia from vasoconstriction, posterior reversible encephalopathy syndrome (PRES), cerebral edema, microhemorrhages.Two articles(primary headache vs secondary headache) • In the study by Matthew et al, the 140 women often presented with headache in the third trimester (56.4%). Diagnoses were divided into primary (65.0%) and secondary (35.0%) disorders. The most common primary headache disorder was migraine (91.2%) and secondary headache disorders were hypertensive disorders (51.0%).In multivariate analysis, a lack of headache history was associated with a nearly fivefold risk of secondary headache, and elevated blood pressure was associated with a 17-fold risk of secondary headache. In comparison to patients with primary headache, patients with secondary headache were more likely to report prolonged attack duration as their change from past headache (61.3% vs 38.0%, p = 0.027).• In the study by Raffaelli et al ,57.6%ofthepatientswerediagnosedwith primaryheadache,mostcommonmigraineandtensiontype headache.Concerningsecondaryheadaches(42.4%) ,themostcommonetiologieswereinfections(29.7%)andhypertensive disorders(22.0%). In cases with a positive headache history, 86% of the patients stated that the current attack was different from the known headache pattern. The conclude that attack features alone cannot adequately discriminate between primary and secondary headache. Additional diagnostic tests leading to final diagnosis include blood, urine and cerebrospinal fluid examination as well as neuroimaging. In presence of the mentioned red flags , low thresholds for additional diagnostic procedures are justified.Para clinicin evaluation of headache in pregnancy Indications for neuroimaging and lumbar puncture are similar to those in nonpregnantadults.Magnetic resonance imaging (MRI) has not been associated with adverse fetal effects. Use of gadolinium should be avoided unless its use significantly improves diagnostic performance and is likely to improve patient outcome, as gadolinium may have adverse effects on offspring.Computed tomography (CT) involves ionizing radiation, but fetal radiation exposure from scatter is minimal during maternal head CT. Iodinated contrast materials cross the placenta and can produce transient effects on Migraine without aura typically improves or remits altogether in most women when pregnant, with improvement or remission observed in nearly 47% of women during the first trimester ,in 83% of women during the second trimester ,in 87% of women during the third trimester.Migraine with aura is less likely to improve during pregnancy than migraine without aura. Approximately 2 percent of women develop their first migraine during pregnancy, usually in the first trimester.The most common time for recurrence is during the postpartum period.Management: Preconception counseling ,no pharmacologic therapies (heat, ice, massage, rest, avoiding triggers (eg, maintaining a regular meal and sleep pattern), and behavioral therapy (eg, relaxation training, biofeedback, cognitive behavioral therapy and Pharmacological therapies.First-line therapy: Acetaminophen alone or combination therapy We initiate therapy with acetaminophen. Acetaminophen (1000 mg) can be an effective treatment of migraine if not respond to acetaminophen alone we suggest Acetaminophen 650 to 1000 mg and metoclopramide 10 mg , Acetaminophen and codeine 30 mg ,Butalbital-acetaminophen-caffeine but Butalbital should be limited to only four to five days per month and codeine to no more than nine days per month. Daily caffeine intake less than 200 mg from all sources is unlikely to be associated with adverse pregnancy effects.Second-line therapy: Aspirin or nonsteroidal anti-infammatory drugs Aspirin and nonsteroidal anti-infammatory drugs (NSAIDs) such as naproxen, ibuprofen, and ketorolac are second-line options, and are safest in the second trimester.Third-line therapiesOpioids — (eg, oxycodone, hydromorphone, meperidine, morphine) are a third-tier option. These drugs should not be used on a chronic basis since can contribute to the development of medication overuse and chronic daily headaches.Triptans — for moderate to severe symptoms in patients who do not respond to other drugs, triptans can be considered. Sumatriptan (50 to 100 mg orally, 4 to 6 mg subcutaneously, or 5 to 20 mg intranasal solution) and rizatriptan.Drugs to reduce nausea and vomiting The H1 antagonists meclizine (25 mg orally), diphenhydramine (25 to 50 mg orally), and promethazine (12.5 to 25 mg orally, per rectum, or intramuscularly) ,Dopamine antagonists such as metoclopramide (10 mg intravenously, intramuscularly, or orally) or phenothiazines such as prochlorperazine (10 mg intravenously, intramuscularly, or orally) or chlorpromazine (25 to 50 mg intramuscularly)and Ondansetron (4 to 8 mg orally or intravenously).Refractory migraine treatment First-line therapy — intravenous hydration, an antiemetic (eg, prochlorperazine 10 mg), and an intravenous opioid.Second-line therapy — Combination therapy with a triptan and droperidol (2.5 mg intravenously every 30 minutes up to three doses).Third-line therapies —Magnesium sulfate: Although the safety of short courses (<5 consecutive days) of magnesium sulfate is well established in pregnancy, its the developing fetal thyroid gland.Lumbar puncture is not contraindicated during pregnancy and should be performed following neuroimaging if increased intracranial pressure or infection is suspected.In the study of Robbins et al., neuroimaging was performed in almost 90% of the cases, with a 18% rate of pathological imaging findings and in the study of Raffaelli et al., only 50% of the patients had neuroimaging and 38% of them had pathologic results.Migraine Migraine without aura typically improves or remits altogether in most women when pregnant, with improvement or remission observed in nearly 47% of women during the first trimester ,in 83% of women during the second trimester ,in 87% of women during the third trimester.Migraine with aura is less likely to improve during pregnancy than migraine without aura. Approximately 2 percent of women develop their first migraine during pregnancy, usually in the first trimester.The most common time for recurrence is during the postpartum period.Management: Preconception counseling ,no pharmacologic therapies (heat, ice, massage, rest, avoiding triggers (eg, maintaining a regular meal and sleep pattern), and behavioral therapy (eg, relaxation training, biofeedback, cognitive behavioral therapy and Pharmacological therapies.First-line therapy: Acetaminophen alone or combination therapy We initiate therapy with acetaminophen. Acetaminophen (1000 mg) can be an effective treatment of migraine if not respond to acetaminophen alone we suggest Acetaminophen 650 to 1000 mg and metoclopramide 10 mg , Acetaminophen and codeine 30 mg ,Butalbital-acetaminophen-caffeine but Butalbital should be limited to only four to five days per month and codeine to no more than nine days per month. Daily caffeine intake less than 200 mg from all sources is unlikely to be associated with adverse pregnancy effects.Second-line therapy: Aspirin or nonsteroidal anti-infammatory drugs Aspirin and nonsteroidal anti-infammatory drugs (NSAIDs) such as naproxen, ibuprofen, and ketorolac are second-line options, and are safest in the second trimester.Third-line therapies Opioids — (eg, oxycodone, hydromorphone, meperidine, morphine) are a third-tier option. These drugs should not be used on a chronic basis since can contribute to the development of medication overuse and chronic daily headaches.Triptans — for moderate to severe symptoms in patients who do not respond to other drugs, triptans can be considered. Sumatriptan (50 to 100 mg orally, 4 to 6 mg subcutaneously, or 5 to 20 mg intranasal solution) and rizatriptan.Drugs to reduce nausea and vomiting The H1 antagonists meclizine (25 mg orally), diphenhydramine (25 to 50 mg orally), and promethazine (12.5 to 25 mg orally, per rectum, or intramuscularly) ,Dopamine antagonists such as metoclopramide (10 mg intravenously, intramuscularly, or orally) or phenothiazines such as prochlorperazine (10 mg intravenously, intramuscularly, or orally) or chlorpromazine (25 to 50 mg intramuscularly)and Ondansetron (4 to 8 mg orally or intravenously).Refractory migraine treatment First-line therapy — intravenous hydration, an antiemetic (eg, prochlorperazine 10 mg), and an intravenous opioid.Second-line therapy — Combination therapy with a triptan and droperidol (2.5 mg intravenously every 30 minutes up to three doses).Third-line therapies —Magnesium sulfate: Although the safety of short courses (<5 consecutive days) of magnesium sulfate is well established in pregnancy, its efficacy for treatment of acute migraine in adults has not been clearly established.Glucocorticoids may be useful in intractable cases. Prednisone (20 mg orally four times daily for two days) or methylprednisolone (4 mg orally, 21 tablets over six days) and peripheral nerve block.Preventive therapy When preventive pharmaceutical treatment is needed for migraine metoprolol and propranolol are the first choice followed by amitriptyline.Botulinum toxin type A is probably safe during pregnancy due to its local mechanisms of action. However, only very few data are available and mainly for its use as cosmetic treatment. As no well-controlled data is available for his indication for now it should only be reserved for severe treatment refractory chronic migraine patients.Three neuromodulation devices have been approved by the FDA for the treatment of migraine: a transcutaneous supraorbital nerve stimulator that is approved as a prophylactic and for acute treatment, a single-pulse transcranial magnetic stimulation device that is approved for both the acute treatment of migraine with aura attacks and as a preventive therapy, noninvasivevagus nerve stimulation that has been approved for the acute treatment of episodic cluster headache attacks as well as for the acute treatment of migraine.These therapies have excellent safety profiles and should be appropriate for pregnant women to use, although, of these devices, only limited investigations have been reported in pregnant women with single-pulse transcranial magnetic stimulation.The peripheral nerve block seemed to be safe,althoughin one study by Govindappagarione patient developed a brief vasovagal attack, and two patients with no acute pain reduction ultimately developed preeclampsia and had postpartum resolution of their headache.Impact Of Migraine On Pregnancy It accompanies with gestational hypertension ,preeclampsia,ischemic stroke and heart disease. Preeclampsia and migraine are interrelated clinical problems in pregnant women. Phenotypic overlap occurs in the symptomatology as both disorders.Recent evidence from a multicenter randomized placebo-controlled trial suggests that the use of low-dose aspirin as a preventive therapy against preterm preeclampsia in pregnant women at higher risk is safe and effective, and it may also be effective as a migraine preventive agent, particularly in women who have migraine with aura.Tension-Type Headache In contrast to migraine, the frequency of tension-type headaches usually does not change during pregnancy since these headaches are not hormonally mediated.Acetaminophen is the first-line analgesic for treatment of tension-type headaches during pregnancy ,Nonsteroidal anti-infammatory drugs (NSAIDs) are a second-line medical therapy, If monotherapy is ineffective, a combination of acetaminophen 500 mg and caffeine 100 mg and nonpharmacologic interventions. Amitriptyline is the drug of the first choice for prophylaxis.Cluster Headache Cluster headache is probably not affected by reproductive hormonal changes.First- and second-line therapies are (oxygen, triptans) ,If response to these therapies is suboptimal, 0.5 mL lidocaine 4% can be placed inside the nostril on the affected side of the head. Ergotamine is effective but absolutely contraindicated during pregnancy.Preventive therapy: Verapamil is the preferred calcium channel blocker because it is relatively safe, and has good tolerability and ease of use. The starting dose is usually 240 mg daily in three divided doses. Prednisone (20 mg orally four times daily for two days) or methylprednisolone (4 mg orally, 21 tablets over six days) .After the first trimester, lithium and topiramate are options. Third-line agents include pizotifen, gabapentin, intranasal application of capsaicin, oral melatonin, and greater occipital nerve block.Key points:• The objective of the ED evaluation of headache is to rule out ominous secondary causes.• Physiologic changes induced by pregnancy