Headache in Pregnancy
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) References to literature on developmental and reproductive toxicology. Website: http://toxnet.nlm.nih.gov 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. Website: http://toxnet.nlm.nih.gov Website: www.OTISpregnancy.org Tel.: +1 866 626 6847
National Library of Medicine Drugs and Lactation Database (LactMed)
Organization of Teratology Information Specialists (OTIS)
Teratogen Information Service (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
References (81)
Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle
Pain
(1993)- et al.
Characteristics and determinants of postpartum ovarian function in women in the United States
Am J Obstet Gynecol
(1993) - et al.
Pregnancy complications and delivery outcomes in pregnant women with severe migraine
Eur J Obstet Gynecol Reprod Biol
(2007) - et al.
Behavioral management of headache triggers: avoidance of triggers is an inadequate strategy
Clin Psychol Rev
(2009) - et al.
Coenzyme Q10 supplementation during pregnancy reduces the risk of pre-eclampsia
Int J Gynaecol Obstet
(2009) - et al.
The relationship between headache and preeclampsia: a case-control study
Eur J Obstet Gynecol Reprod Biol
(2005) - et al.
The global burden of headache: a documentation of headache prevalence and disability worldwide
Cephalalgia
(2007) - et al.
Trigeminal autonomic cephalalgias: current and future treatments
Headache
(2007) - et al.
Cluster headache: a prospective clinical study with diagnostic implications
Neurology
(2002) - et al.
Risk of preterm delivery and hypertensive disorders of pregnancy in relation to maternal co-morbid mood and migraine disorders during pregnancy
Paediatr Perinat Epidemiol
(2011)
Disparities in rates of unintended pregnancy in the United States, 1994 and 2001
Perspect Sex Reprod Health
Headache during pregnancy
Cephalalgia
Headache and transient focal neurological symptoms during pregnancy, a prospective cohort
Acta Neurol Scand
The effect of pregnancy and parity on headache prevalence: the Head-HUNT study
Headache
Cluster headache in women: evidence of hypofertility(?) Headaches in relation to menstruation and pregnancy
Cephalalgia
Cluster headache in women: relation with menstruation, use of oral contraceptives, pregnancy, and menopause
J Neurol Neurosurg Psychiatry
Incidence of migraine relative to menstrual cycle phases of rising and falling estrogen
Neurology
Prevention of menstrual attacks of migraine: a double-blind placebo-controlled crossover study
Neurology
Oestrogen and attacks of migraine with and without aura
Lancet Neurol
Some clinical aspects of migraine
Arch Neurol
A study of migraine in pregnancy
Neurology
Classic and common migraine suggestive clinical evidence of two separate entities
Funct Neurol
Migraine and pregnancy: a prospective study in 703 women after delivery
Neurology
Migraine with aura and migraine without aura: an epidemiological study
Cephalalgia
Migraine without aura and reproductive life events: a clinical epidemiological study in 1300 women
Headache
Sex-hormone-related events in migrainous females. A clinical comparative study between migraine with aura and migraine without aura
Cephalalgia
Migraine without aura and migraine with aura are distinct clinical entities: a study of four hundred and eighty-four male and female migraineurs from the general population
Cephalalgia
Headaches and hormones: subjective versus objective assessment
Headache Q
A 40-year follow-up of school children with migraine
Cephalalgia
The prevalence of migraine in women aged 40-74 years: a population-based study
Cephalalgia
Migraine with aura and reproductive life events: a case control study
Cephalalgia
Women's issues of migraine in tertiary care
Headache
Headache recurrence in pregnant women with migraine
Headache
Headache during pregnancy and in the postpartum: a prospective study
Headache
Longitudinal prospective study of headache during pregnancy and postpartum
Headache
Course of migraine during pregnancy and postpartum: a prospective study
Cephalalgia
Headaches during pregnancy in women with a prior history of menstrual headaches
Arq Neuropsiquiatr
Headache and migraine during pregnancy and puerperium: the MIGRA-study
J Headache Pain
Migraine occurring for the first time in pregnancy
Headache
Migraine aura or transient ischemic attacks? A five-year follow-up case-control study of women with transient central nervous system disorders in pregnancy
BMC Med
Cited by (45)
Headache in pregnancy
2023, The Brain of the Critically Ill Pregnant WomanHeadache in Pregnancy
2022, Otolaryngologic Clinics of North AmericaCitation Excerpt :The ICHD-3 diagnostic criteria for these diagnoses are included in Table 2. Most pregnant women with preexisting migraine tend to experience a decrease or complete resolution of migraine symptoms during pregnancy.4,6,7 This effect may be attributed to an increase in the pain threshold secondary to elevated estrogen and endogenous opioid levels and the absence of fluctuating hormone levels during pregnancy.8
Epidural analgesia in the obese obstetric patient: a retrospective and comparative study with non-obese patients at a tertiary hospital
2021, Brazilian Journal of Anesthesiology (English Edition)Citation Excerpt :As previously mentioned, the technique in the obese parturient has been performed by experienced anesthesiologists, so the probability of success was higher in such patients. Around 50-80% of patients with ADP develop PDPH.19–22 Our study has not found a higher PDPH incidence among obese population, which matches the results obtained in previous studies.
Late Pregnancy and Postpartum Emergencies
2019, Emergency Medicine Clinics of North AmericaHeadache in the Emergency Department: Avoiding Misdiagnosis of Dangerous Secondary Causes
2016, Emergency Medicine Clinics of North AmericaCitation Excerpt :In patients older than 60 years with a new headache, especially if accompanied by polymyalgia rheumatic (PMR) or symptoms such as scalp tenderness, jaw claudication, or visual symptoms, consider giant cell arteritis (see later in this article). The most likely etiologies of headache in patients who are pregnant or postpartum are similar to the general population with primary headaches, such as tension-type and migraines, being most common.44,45 However, patients are at increased risk for secondary headaches during pregnancy, warranting a meticulous evaluation for etiologies such as preeclampsia, cerebral venous thrombosis, and pituitary apoplexy.
Prevalence and course of pregnancy symptoms using self-reported pregnancy app symptom tracker data
2023, npj Digital Medicine
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.