Elsevier

Neurologic Clinics

Volume 30, Issue 3, August 2012, Pages 835-866
Neurologic Clinics

Headache in Pregnancy

https://doi.org/10.1016/j.ncl.2012.04.001Get rights and content

Introduction

Most people have headaches at some point during their lives. The common primary headaches, tension-type headache and migraine, are predominantly a female affliction, particularly during childbearing years. A review of global population-based data identified a lifetime prevalence of tension-type headache in 49% of women and 42% of men, and a lifetime prevalence of migraine in 22% of women and 10% of men.1 Trigeminal autonomic cephalalgias are rare, affecting less than 1 per 1000 of the population.2 Whereas paroxysmal hemicrania has a 2.1 to 2.4:1 female to male ratio, cluster headache is predominantly a male disorder (female to male ratio 1:2.5–7.5) but is often undiagnosed in women.2, 3

Although primary headaches typically improve during pregnancy, some women experience more frequent and severe headaches while a few develop headache for the first time. Primary headaches do not in themselves pose any threat to pregnancy, but migraine is associated with increased risk of hypertensive disorders of pregnancy. Frequent prepregnancy headache is a strong predictor of poor general and emotional health during pregnancy and should alert the health care professional to assess these women for depressive disorders.4 Drug treatment is usually necessary for control of severe headaches, so health care providers need to advise women on safe and effective treatment during pregnancy and lactation. Of more concern is that approximately half of the pregnancies in the United States are unplanned, of which more than 40% continue to birth.5 Hence health care providers need accurate knowledge of the likely effects of inadvertent drug use on the outcome of the pregnancy.

Section snippets

Tension-Type Headache

Despite being more prevalent than migraine, there are few studies assessing the effect of pregnancy on tension-type headache. In a retrospective cross-sectional population-based study of 102 women with tension-type headache, 28% reported improvement during pregnancy, 67% reported no change, and 5% reported increased headache.6 In a study of 33 women with tension-type headache completing a questionnaire 3 days postpartum, 82% reported improvement during pregnancy (49% complete remission) and 18%

Outcome of Pregnancy

The majority of studies confirms that migraine with or without aura is not associated with significant adverse effects on the outcome of pregnancy. In a retrospective study of 450 migraineurs who had had 1142 pregnancies and 136 controls who had had 342 pregnancies, the incidence of miscarriage or stillbirth was similar, both overall (17% migraineurs vs 18% controls) and during the first trimester (13% migraineurs vs 13% controls).42 The incidence of birth defects was also similar for both

Investigations for headache in pregnancy and lactation

Routine investigations should be deferred until after delivery. The majority of headaches can be diagnosed from the history and examination without the need for investigations, which are indicated only to exclude suspected secondary headache resulting from underlying abnormality. Should investigations be required, they are the same as for nonpregnant women. Most diagnostic radiologic procedures are associated with little, if any, significant fetal risks. The American College of Obstetricians

Management of headache during pregnancy and lactation

The options for management are drugs to treat acute symptoms, drugs to prevent attacks, and nonpharmacologic interventions to prevent attacks. These agents can be used alone or in combination, depending on headache frequency and individual preferences.

Evidence for safety of drugs in pregnancy and lactation

There are several sources in the United States that provide information on safety of drugs during pregnancy and lactation, listed under “Resources.” These resources provided the evidence for the recommendations listed here. The US Food and Drugs Administration (FDA) pregnancy labeling has 5 categories: A, B, C, D, and X (Box 1). These categories can be misleading, as categories C, D, and X are not only based on risk but consider risk versus benefit, so drugs in each of the 3 categories may pose

Drugs taken for headaches during pregnancy and lactation

This section reviews drugs used for the acute treatment (Table 5) and prophylactic treatment (Table 6) of headache.

Emergency treatment of headache

Magnesium is used during pregnancy for the management of preeclampsia and can also be used to treat migraine. Intravenous magnesium sulfate, 1 g given intravenously over 15 minutes, was well tolerated and effective in a randomized, single-blind, placebo-controlled trial of 30 patients with migraine.73 A combination of intravenous prochlorperazine, 10 mg 8-hourly together with intravenous magnesium sulfate, 1 g 12-hourly, was used successfully to abort 2 cases of prolonged migraine aura during

Summary

Primary headaches, particularly migraine, are affected by the hormonal changes during pregnancy and lactation. The headaches pose no threat to the pregnancy, so it is important that treatment is equally benign. However, women with migraine should be carefully monitored during pregnancy because they are at increased risk of hypertensive disorders of pregnancy and stroke. Most drugs used to treat headaches can be continued throughout pregnancy. Aspirin and NSAIDs are safe in the first and second

Resources

National Library of Medicine Developmental and Reproductive Toxicology Database (DART)

  1. References to literature on developmental and reproductive toxicology.

  2. Website: http://toxnet.nlm.nih.gov

National Library of Medicine Drugs and Lactation Database (LactMed)
  1. A peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed. Among the data included are maternal and infant levels of drugs, possible effects on breastfed infants and on lactation, and alternative drugs to consider.

  2. Website: http://toxnet.nlm.nih.gov

Organization of Teratology Information Specialists (OTIS)
  1. Website: www.OTISpregnancy.org

  2. Tel.: +1 866 626 6847

Teratogen Information Service (TERIS)
  1. Website: http://depts.washington.edu/terisweb/teris/

UK Teratology Information Service

Case study

V.S., a 34-year-old lawyer, is 12 weeks pregnant with her first child. She had a miscarriage 18 months ago, at 9 weeks. She had migraine without aura since the age of 11 years. Initially she only had occasional attacks, but over the last year she was having an attack twice a month that did not always respond to sumatriptan. She was started on amitriptyline, 50 mg 5 months ago, which reduced the frequency to 1 attack every 4 to 6 weeks, which she could then control with sumatriptan. She stopped

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    The author has acted as a paid consultant to, and/or her department has received research funding from Addex, Allergan, AstraZeneca, Bayer Healthcare, Berlin-Chemie, BTG, Endo Pharmaceuticals, GlaxoSmithKline, Menarini, Merck, Pozen and Unipath. She received no financial support for the preparation of this article.

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