Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Headache in pregnant and postpartum women

Men-Jean Lee, MD
Debra Guinn, MD, FACOG
Susan Hickenbottom, MD, MS
Section Editors
Charles J Lockwood, MD, MHCM
Jerry W Swanson, MD, MHPE
Deputy Editor
Vanessa A Barss, MD, FACOG


Headache is common among women in their childbearing years: In the Norwegian Head-HUNT study, 60 percent of women ≤40 years of age reported experiencing a headache within the previous year [1]. For women with a history of headache, the effect of pregnancy on the frequency and severity of headache, the effect of headache on pregnancy, and the safety of maternal headache treatment for the fetus are major concerns. For women with headache first presenting during pregnancy or postpartum, a diagnostic evaluation is indicated and should include evaluation for pregnancy-related causes of headache: Preeclampsia with severe features always needs to be excluded in women over 20 weeks of gestation.

This topic will discuss issues specific to diagnosis and management of headache in pregnant and postpartum women. The diagnosis and treatment of headaches in the general population are reviewed separately. (See "Evaluation of headache in adults" and "Evaluation of the adult with headache in the emergency department".)


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 have preeclampsia [2]. Criteria for diagnosis of preeclampsia are described in the table and form the basis for evaluation (table 1). The diagnosis can be excluded in normotensive women. (See "Preeclampsia: Clinical features and diagnosis".)

Headache is a feature of the severe spectrum of preeclamptic disease and a potential precursor of eclampsia (preeclampsia with seizure) [3]. The headache is typically diffuse (holocephalic), constant, throbbing, and mild to severe in intensity. Blurred vision, photophobia, and confusion and alteration in the level of consciousness may occur. These symptoms are similar to those of migraine, except migraine pain is frequently unilateral. In women with mildly increased blood pressure due to pain, the diagnosis of preeclampsia-related headache is supported by the presence of other severe features of the disease: scotomata or other visual problems (eg, blurred vision, double vision, photophobia, amaurosis, hemianopsia), epigastric pain, or laboratory findings of thrombocytopenia, elevated liver chemistries, hemolysis, and/or elevated creatinine.

The neurologic examination is usually normal in preeclampsia. Focal neurologic symptoms suggest complicated preeclampsia (eg, stroke) or an alternative diagnosis (eg, migraine with aura, stroke unrelated to preeclampsia). Although seizure is the key finding of eclampsia, it also occurs with other intracranial pathology, including cerebral venous thrombosis, hemorrhage, and tumor (see "Eclampsia"). A neurologist or neurosurgeon should be consulted in women with an abnormal neurologic examination or severe headache that persists after preeclampsia\eclampsia has been excluded. Women in whom preeclampsia\eclampsia is suspected should have an obstetrical or maternal-fetal medicine consultation.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Aug 30, 2017.
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 ©2017 UpToDate, Inc.
  1. Aegidius K, Zwart JA, Hagen K, Stovner L. The effect of pregnancy and parity on headache prevalence: the Head-HUNT study. Headache 2009; 49:851.
  2. Melhado EM, Maciel JA Jr, Guerreiro CA. Headache during gestation: evaluation of 1101 women. Can J Neurol Sci 2007; 34:187.
  3. 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.
  4. 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.
  5. 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.
  6. Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996; 334:494.
  7. Cunningham FG, Twickler D. Cerebral edema complicating eclampsia. Am J Obstet Gynecol 2000; 182:94.
  8. Contag SA, Bushnell C. Contemporary management of migrainous disorders in pregnancy. Curr Opin Obstet Gynecol 2010; 22:437.
  9. Marcus DA. Managing headache during pregnancy and lactation. Expert Rev Neurother 2008; 8:385.
  10. Silberstein SD. Evaluation and emergency treatment of headache. Headache 1992; 32:396.
  11. Goldszmidt E, Kern R, Chaput A, Macarthur A. The incidence and etiology of postpartum headaches: a prospective cohort study. Can J Anaesth 2005; 52:971.
  12. Stella CL, Jodicke CD, How HY, et al. Postpartum headache: is your work-up complete? Am J Obstet Gynecol 2007; 196:318.e1.
  13. Kelly JC, Safain MG, Roguski M, et al. Postpartum internal carotid and vertebral arterial dissections. Obstet Gynecol 2014; 123:848.
  14. Goldberg-Stein SA, Liu B, Hahn PF, Lee SI. Radiation dose management: part 2, estimating fetal radiation risk from CT during pregnancy. AJR Am J Roentgenol 2012; 198:W352.
  15. MacGregor EA. Headache in pregnancy. Neurol Clin 2012; 30:835.
  16. Aromaa M, Rautava P, Helenius H, Sillanpää ML. Prepregnancy headache and the well-being of mother and newborn. Headache 1996; 36:409.
  17. Dixit A, Bhardwaj M, Sharma B. Headache in pregnancy: a nuisance or a new sense? Obstet Gynecol Int 2012; 2012:697697.
  18. Agerson AN, Scavone BM. Prophylactic epidural blood patch after unintentional dural puncture for the prevention of postdural puncture headache in parturients. Anesth Analg 2012; 115:133.
  19. Lipton RB, Stewart WF. Migraine in the United States: a review of epidemiology and health care use. Neurology 1993; 43:S6.
  20. Ertresvåg JM, Zwart JA, Helde G, et al. Headache and transient focal neurological symptoms during pregnancy, a prospective cohort. Acta Neurol Scand 2005; 111:233.
  21. Sances G, Granella F, Nappi RE, et al. Course of migraine during pregnancy and postpartum: a prospective study. Cephalalgia 2003; 23:197.
  22. Silberstein SD. Headaches in pregnancy. Neurol Clin 2004; 22:727.
  23. Wall VR. Breastfeeding and migraine headaches. J Hum Lact 1992; 8:209.
  24. Marcus DA, Scharff L, Turk D. Longitudinal prospective study of headache during pregnancy and postpartum. Headache 1999; 39:625.
  25. Kittner SJ, Stern BJ, Feeser BR, et al. Pregnancy and the risk of stroke. N Engl J Med 1996; 335:768.
  26. 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.
  27. James AH, Bushnell CD, Jamison MG, Myers ER. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol 2005; 106:509.
  28. Bushnell CD, Jamison M, James AH. Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study. BMJ 2009; 338:b664.
  29. Menon R, Bushnell CD. Headache and pregnancy. Neurologist 2008; 14:108.
  30. Adeney KL, Williams MA, Miller RS, et al. Risk of preeclampsia in relation to maternal history of migraine headaches. J Matern Fetal Neonatal Med 2005; 18:167.
  31. Simbar M, Karimian Z, Afrakhteh M, et al. Increased risk of pre-eclampsia (PE) among women with the history of migraine. Clin Exp Hypertens 2010; 32:159.
  32. Facchinetti F, Allais G, Nappi RE, et al. Migraine is a risk factor for hypertensive disorders in pregnancy: a prospective cohort study. Cephalalgia 2009; 29:286.
  33. 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.
  34. www.reprotox.org (Accessed on October 18, 2012).
  35. Mathew NT. Transformed migraine, analgesic rebound, and other chronic daily headaches. Neurol Clin 1997; 15:167.
  36. Rapoport A, Stang P, Gutterman DL, et al. Analgesic rebound headache in clinical practice: data from a physician survey. Headache 1996; 36:14.
  37. Evans EW, Lorber KC. Use of 5-HT1 agonists in pregnancy. Ann Pharmacother 2008; 42:543.
  38. Olesen C, Steffensen FH, Sorensen HT, et al. Pregnancy outcome following prescription for sumatriptan. Headache 2000; 40:20.
  39. Marchenko A, Etwel F, Olutunfese O, et al. Pregnancy outcome following prenatal exposure to triptan medications: a meta-analysis. Headache 2015; 55:490.
  40. Penzien DB, Taylor FR. Headache toolbox. Behavioral and other nonpharmacologic treatments for headache. Headache 2014; 54:955.
  41. Demirkaya S, Vural O, Dora B, Topçuoğlu MA. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache 2001; 41:171.
  42. Rozen TD. Aborting a prolonged migrainous aura with intravenous prochlorperazine and magnesium sulfate. Headache 2003; 43:901.
  43. Wang SJ, Silberstein SD, Young WB. Droperidol treatment of status migrainosus and refractory migraine. Headache 1997; 37:377.
  44. US Food and Drug Administration. Inapsine (droperidol) Dear Healthcare Professional Letter Dec 2001. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm173778.htm (Accessed on June 24, 2011).
  45. Choi H, Parmar N. The use of intravenous magnesium sulphate for acute migraine: meta-analysis of randomized controlled trials. Eur J Emerg Med 2014; 21:2.
  46. Lucas S. Medication use in the treatment of migraine during pregnancy and lactation. Curr Pain Headache Rep 2009; 13:392.
  47. 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.
  48. Govindappagari S, Grossman TB, Dayal AK, et al. Peripheral nerve blocks in the treatment of migraine in pregnancy. Obstet Gynecol 2014; 124:1169.
  49. http://www.fda.gov/Drugs/DrugSafety/ucm350684.htm (Accessed on May 15, 2013).
  50. Paulson GW. Headaches in women, including women who are pregnant. Am J Obstet Gynecol 1995; 173:1734.
  51. 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.
  52. Karlı N, Baykan B, Ertaş M, et al. Impact of sex hormonal changes on tension-type headache and migraine: a cross-sectional population-based survey in 2,600 women. J Headache Pain 2012; 13:557.
  53. Marozio L, Facchinetti F, Allais G, et al. Headache and adverse pregnancy outcomes: a prospective study. Eur J Obstet Gynecol Reprod Biol 2012; 161:140.
  54. Manzoni GC, Micieli G, Granella F, et al. Cluster headache in women: clinical findings and relationship with reproductive life. Cephalalgia 1988; 8:37.
  55. 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.
  56. Calhoun AH, Peterlin BL. Treatment of cluster headache in pregnancy and lactation. Curr Pain Headache Rep 2010; 14:164.
  57. Ekbom K, Waldenlind E. Cluster headache in women: evidence of hypofertility(?) Headaches in relation to menstruation and pregnancy. Cephalalgia 1981; 1:167.
  58. Bahra A, May A, Goadsby PJ. Cluster headache: a prospective clinical study with diagnostic implications. Neurology 2002; 58:354.
  59. Jürgens TP, Schaefer C, May A. Treatment of cluster headache in pregnancy and lactation. Cephalalgia 2009; 29:391.
  60. Giraud P, Chauvet S. Cluster headache during pregnancy: case report and literature review. Headache 2009; 49:136.
Topic Outline