Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point of care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: 5,100 physician authors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

For more information, click below.


Subscribers log in here


Headache in pregnancy

INTRODUCTION

Headaches occur in over 80 percent of women during their childbearing years, thus they often present during pregnancy [1,2]. The hormonal changes accompanying the menstrual cycle, pregnancy, and the postpartum period are thought to be responsible for many headaches in women of reproductive age [3]. More than 90 percent of these headaches are either migraine or tension-type headaches [4], both of which are typically more severe in women than in men [5].

Unfortunately, no large trials of headache therapy in pregnant women are available to provide data on which to base therapeutic recommendations. The major consideration is to "do no harm" since a history of headaches does not appear to adversely affect pregnancy outcome [6]. Treatment decisions are made according to recommendations for nonpregnant adults with avoidance of drugs that are considered teratogenic or otherwise known to be harmful in pregnancy (eg, uterotonic agents, vasoconstrictors). The number of medications and dosages should be limited to the minimum needed to control symptoms adequately.

Specific therapeutic choices for abortive and prophylactic therapy should be based on the patient's prior treatment successes and failures, gestational age, and co-morbid conditions. The risk of teratogenicity or adverse perinatal outcome is generally low. Patients need to have realistic expectations regarding the limits of therapy and physicians need to be willing to treat these patients aggressively, as needed.

The pathophysiology of headaches in women and the management of headache related to pregnancy will be discussed here. The diagnosis and treatment of headaches in the general population are reviewed separately. (See "Evaluation of headache in adults" and "Headache syndromes other than migraine".)

MIGRAINE HEADACHE

The prevalence of migraine headache is higher in women than in men and peaks during the childbearing years. Approximately 18 percent of American women suffer from severe migraine headaches; many others have mild to moderate interference with their usual activities [7].

                 

Subscribers log in here

To continue reading this article you must have access through your hospital or your group practice, log in to your personal subscription, or purchase a personal subscription. For more information, click below.
Literature review current through: 20.6: May 2012
This topic last updated: Jan 5, 2012
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use (click here) ©2012 UpToDate, Inc.
References
Top
  1. Waters WE, O'Connor PJ. Epidemiology of headache and migraine in women. J Neurol Neurosurg Psychiatry 1971; 34:148.
  2. Maggioni F, Alessi C, Maggino T, Zanchin G. Headache during pregnancy. Cephalalgia 1997; 17:765.
  3. Scharff L, Marcus DA, Turk DC. Headache during pregnancy and in the postpartum: a prospective study. Headache 1997; 37:203.
  4. Hainline B. Headache. Neurol Clin 1994; 12:443.
  5. Bille B. A 40-year follow-up of school children with migraine. Cephalalgia 1997; 17:488.
  6. Aromaa M, Rautava P, Helenius H, Sillanpää ML. Prepregnancy headache and the well-being of mother and newborn. Headache 1996; 36:409.
  7. Lipton RB, Stewart WF. Migraine in the United States: a review of epidemiology and health care use. Neurology 1993; 43:S6.
  8. Brandes JL. The influence of estrogen on migraine: a systematic review. JAMA 2006; 295:1824.
  9. Martin VT, Behbehani M. Ovarian hormones and migraine headache: understanding mechanisms and pathogenesis--part I. Headache 2006; 46:3.
  10. Martin VT, Behbehani M. Ovarian hormones and migraine headache: understanding mechanisms and pathogenesis--part 2. Headache 2006; 46:365.
  11. Marcus DA. Interrelationships of neurochemicals, estrogen, and recurring headache. Pain 1995; 62:129.
  12. Somerville BW. Estrogen-withdrawal migraine. I. Duration of exposure required and attempted prophylaxis by premenstrual estrogen administration. Neurology 1975; 25:239.
  13. Somerville BW. The role of progesterone in menstrual migraine. Neurology 1971; 21:853.
  14. Rasmussen BK. Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain 1993; 53:65.
  15. Sances G, Granella F, Nappi RE, et al. Course of migraine during pregnancy and postpartum: a prospective study. Cephalalgia 2003; 23:197.
  16. Silberstein SD. Headaches in pregnancy. Neurol Clin 2004; 22:727.
  17. Melhado EM, Maciel JA Jr, Guerreiro CA. Headache during gestation: evaluation of 1101 women. Can J Neurol Sci 2007; 34:187.
  18. Wall VR. Breastfeeding and migraine headaches. J Hum Lact 1992; 8:209.
  19. Menon R, Bushnell CD. Headache and pregnancy. Neurologist 2008; 14:108.
  20. Kittner SJ, Stern BJ, Feeser BR, et al. Pregnancy and the risk of stroke. N Engl J Med 1996; 335:768.
  21. Sharshar T, Lamy C, Mas JL. Incidence and causes of strokes associated with pregnancy and puerperium. A study in public hospitals of Ile de France. Stroke in Pregnancy Study Group. Stroke 1995; 26:930.
  22. Lipton RB, Baggish JS, Stewart WF, et al. Efficacy and safety of acetaminophen in the treatment of migraine: results of a randomized, double-blind, placebo-controlled, population-based study. Arch Intern Med 2000; 160:3486.
  23. www.Reprotox.org (accessed July 1, 2009).
  24. Nonsteroidal inflammatory agents. www.reprotox.org (Accessed on January 05, 2012).
  25. Mathew NT. Transformed migraine, analgesic rebound, and other chronic daily headaches. Neurol Clin 1997; 15:167.
  26. Rapoport A, Stang P, Gutterman DL, et al. Analgesic rebound headache in clinical practice: data from a physician survey. Headache 1996; 36:14.
  27. Olesen C, Steffensen FH, Sorensen HT, et al. Pregnancy outcome following prescription for sumatriptan. Headache 2000; 40:20.
  28. www.Reprotox.com. (Accessed April 9, 2009).
  29. Soldin OP, Dahlin J, O'Mara DM. Triptans in pregnancy. Ther Drug Monit 2008; 30:5.
  30. Evans EW, Lorber KC. Use of 5-HT1 agonists in pregnancy. Ann Pharmacother 2008; 42:543.
  31. Matok I, Gorodischer R, Koren G, et al. The safety of metoclopramide use in the first trimester of pregnancy. N Engl J Med 2009; 360:2528.
  32. Einarson A, Maltepe C, Navioz Y, et al. The safety of ondansetron for nausea and vomiting of pregnancy: a prospective comparative study. BJOG 2004; 111:940.
  33. Lucas S. Medication use in the treatment of migraine during pregnancy and lactation. Curr Pain Headache Rep 2009; 13:392.
  34. Solomon GD, Cady RK, Klapper JA, Ryan RE Jr. Standards of care for treating headache in primary care practice. National Headache Foundation. Cleve Clin J Med 1997; 64:373.
  35. Wang SJ, Silberstein SD, Young WB. Droperidol treatment of status migrainosus and refractory migraine. Headache 1997; 37:377.
  36. Snyder SW, Cardwell MS. Neuromuscular blockade with magnesium sulfate and nifedipine. Am J Obstet Gynecol 1989; 161:35.
  37. Waisman GD, Mayorga LM, Cámera MI, et al. Magnesium plus nifedipine: potentiation of hypotensive effect in preeclampsia? Am J Obstet Gynecol 1988; 159:308.
  38. Paulson GW. Headaches in women, including women who are pregnant. Am J Obstet Gynecol 1995; 173:1734.
  39. Manzoni GC, Micieli G, Granella F, et al. Cluster headache in women: clinical findings and relationship with reproductive life. Cephalalgia 1988; 8:37.
  40. van Vliet JA, Favier I, Helmerhorst FM, et al. Cluster headache in women: relation with menstruation, use of oral contraceptives, pregnancy, and menopause. J Neurol Neurosurg Psychiatry 2006; 77:690.
  41. Ekbom K, Waldenlind E. Cluster headache in women: evidence of hypofertility(?) Headaches in relation to menstruation and pregnancy. Cephalalgia 1981; 1:167.
  42. Bahra A, May A, Goadsby PJ. Cluster headache: a prospective clinical study with diagnostic implications. Neurology 2002; 58:354.
  43. Jürgens TP, Schaefer C, May A. Treatment of cluster headache in pregnancy and lactation. Cephalalgia 2009; 29:391.
  44. Witlin AG, Saade GR, Mattar F, Sibai BM. Risk factors for abruptio placentae and eclampsia: analysis of 445 consecutively managed women with severe preeclampsia and eclampsia. Am J Obstet Gynecol 1999; 180:1322.
  45. Belfort MA, Saade GR, Grunewald C, et al. Association of cerebral perfusion pressure with headache in women with pre-eclampsia. Br J Obstet Gynaecol 1999; 106:814.
  46. Schwartz RB, Jones KM, Kalina P, et al. Hypertensive encephalopathy: findings on CT, MR imaging, and SPECT imaging in 14 cases. AJR Am J Roentgenol 1992; 159:379.
  47. Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996; 334:494.
  48. Cunningham FG, Twickler D. Cerebral edema complicating eclampsia. Am J Obstet Gynecol 2000; 182:94.
  49. Evans RW, Armon C, Frohman EM, Goodin DS. Assessment: prevention of post-lumbar puncture headaches: report of the therapeutics and technology assessment subcommittee of the american academy of neurology. Neurology 2000; 55:909.
  50. Mueller-Mang C, Mang T, Pirker A, et al. Posterior reversible encephalopathy syndrome: do predisposing risk factors make a difference in MRI appearance? Neuroradiology 2009; 51:373.
  51. Amagada JO, Kondagunta H, Afshan N, et al. Posterior reversible encephalopathy syndrome secondary to eclampsia. J Obstet Gynaecol 2008; 28:646.
  52. Stella CL, Jodicke CD, How HY, et al. Postpartum headache: is your work-up complete? Am J Obstet Gynecol 2007; 196:318.e1.
  53. Singhal AB, Kimberly WT, Schaefer PW, Hedley-Whyte ET. Case records of the Massachusetts General Hospital. Case 8-2009. A 36-year-old woman with headache, hypertension, and seizure 2 weeks post partum. N Engl J Med 2009; 360:1126.
  54. LactMed at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT (accessed April 11, 2008).
  55. Benjamin J, Benjamin M. Panic disorder masquerading as pre-eclampsia. Eur J Obstet Gynecol Reprod Biol 1993; 51:81.
  56. Kupferminc MJ, Eldor A, Steinman N, et al. Increased frequency of genetic thrombophilia in women with complications of pregnancy. N Engl J Med 1999; 340:9.
  57. Martinelli I, Sacchi E, Landi G, et al. High risk of cerebral-vein thrombosis in carriers of a prothrombin-gene mutation and in users of oral contraceptives. N Engl J Med 1998; 338:1793.
  58. Silberstein SD. Evaluation and emergency treatment of headache. Headache 1992; 32:396.
  59. Ramchandren S, Cross BJ, Liebeskind DS. Emergent headaches during pregnancy: correlation between neurologic examination and neuroimaging. AJNR Am J Neuroradiol 2007; 28:1085.