Evaluation of Headache During Pregnancy

Examples of Benign and Serious Pregnancy Headaches

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While there are many new symptoms that occur during pregnancy, like weight gain, acid reflux, and back pain, there can also be worsening or improvement of existing medical conditions. For instance, migraines tend to improve during pregnancy, especially in the second and third trimesters. Other conditions, like headache disorders unique to pregnancy, may also arise.

Headache Evaluation During Pregnancy

When evaluating your headache, your doctor will perform a detailed history.

He may ask you questions pertaining to any medical conditions you suffer from, like high blood pressure or depression, or whether you are taking any medications or over-the-counter supplements, like vitamins, caffeine,or laxatives.

Your doctor will also inquire as to the characteristics of your headache such as how intense it is, how long it has lasted, or whether there are associated symptoms like nausea or vomiting. This is done in order to make an accurate diagnosis, as well as to assess headache warning signs and rule out medical emergencies.

Some specific headache warning signs (which may signal dangerous headaches in pregnancy) that warrant immediate medical attention include:

  • "Worst headache of my life"
  • Blurry vision
  • Neurological symptoms like weakness or numbness
  • Headache with fever and/or stiff neck
  • Headache with high blood pressure and/or swelling of the legs and feet
  • Headache related to exertion

    Primary Headaches During Pregnancy

    The three most common primary headache disorders are migraines, tension-type headaches, and cluster headaches. While women can develop a new headache disorder during pregnancy, typically these disorders have already existed and can be worsened during the first trimester, especially with the change in hormone levels in the body and the added stress occurring.

    Migraines are the most common headache in pregnancy but are generally less severe and occur less often than those outside of pregnancy. There is some scientific evidence that women with migraines may be at a higher risk of developing preeclampsia and/or preterm birth, although more research needs to be done to tease apart this relationship.

    Idiopathic Intracranial Hypertension

    Idiopathic Intracranial Hypertension (IIH) is a serious medical disorder that is commonly seen in obese women of child-bearing years. This disorder causes a headache along with vision changes and pulsatile tinnitus - when people hear a rhythmic sound that matches their heartbeat. People with IIH will have normal brain imaging but will have elevated cerebrospinal fluid pressures or CSF pressure when a lumbar puncture is performed.

    In addition, women with IIH will have papilledema, a condition characterized by swelling behind the eye due to increased fluid pressure in the brain. Treatment is geared towards weight loss or weight management and reduction of the elevated intracranial pressure.

    Sometimes intracranial hypertension is caused by another medical condition - referred to as secondary intracranial hypertension. The most common cause of secondary intracranial hypertension is cerebral venous thrombosis, which can occur at any stage of pregnancy but is most common during the postpartum period.

    Headaches From Preeclampsia/Eclampsia

    Preeclampsia and eclampsia are serious medical conditions that occur after 20 weeks gestation, in addition to the postpartum period. Preeclampsia causes high blood pressure and protein in the urine. Severe preeclampsia causes a very high blood pressure, low urine output, liver problems, vision changes, low number of platelets, and intrauterine growth restriction. Eclampsia is a potentially fatal condition and occurs when a woman has  seizures, blindness, and/or coma in the face of severe preeclampsia.

    In both preeclampsia and eclampsia, headache is a common symptom and can resemble that of a migraine, characterized often by a throbbing sensation and accompanied by nausea and photophobia (sensitivity to light) and/or phonophobia (sensitivity to sound). In fact, according to an article in Headache, women with a history of migraines are nearly four times more likely to develop preeclampsia than those without a history of migraines.

    Treatment of preeclampsia and eclampsia generally involves delivery of the baby, in addition to magnesium sulfate, calcium channel blockers,and possibly anti-seizure medications.

    Reversible Cerebral Vascular Syndrome

    Reversible cerebral vascular syndrome, also known as Call-Fleming syndrome, is another headache syndrome that can be triggered by pregnancy and may also occur in the postpartum period. People this headache syndrome usually describe a thunderclap headache, which is a severe and sudden explosive onset of head pain.

    The cause of this syndrome is unknown, but the origin of the pain is believed to be related to spasm of the arteries in the brain. Treatment is with calcium channel blockers—a blood pressure medication that helps to dilate or open the brain arteries.

    This all being said, then a woman goes to the emergency room with a thunderclap headache, an exhaustive approach to rule out a subarachnoid hemorrhage is imperative before assuming the patient to have a reversible cerebral vascular syndrome.

    What Does This Mean for Me?

    In addition to IIH, preeclampsia, and reversible cerebral vascular syndrome, there are other potential causes of dangerous headaches, like stroke, meningitis, or pituitary apoplexy.

    This all being said, most headaches in pregnancy are not dangerous. Still, if you experience a headache during pregnancy that is not eased with a cold compress, sleep, caffeine (if you suspect a caffeine withdrawal headache) relaxation, and/or food, or if your headache follows a different pattern or shows headache warning signs, be sure to contact your doctor right away.

    Sources:

    Adeney KL, Williams MA. Migraine headaches and preeclampsia: an epidemiologic review. Headache. 2006;46:794–803

    Digre KB. Headaches during pregnancy. Clin Obstet Gynecol. 2013 Jun;56(2):317-29.

    Lee M-J, Guinn D, Hickenbottom S. Headache in pregnant and postpartum women. In: UpToDate, Basow DS (Ed), UpToDate, Waltham, MA, 2014.

    Moustafa RR, Allen CM, Baron JC. Call-Fleming syndrome associated with subarachnoid hemorrhage: three new cases. J. Neurol. Neurosurg. Psychiatr. May 2008;79(5): 602–5.

    Nappi RE, Albani F, Sances G, Terreno E, Brambilia E, Polatti F. Headaches during pregnancy. Curr Pain Headache Rep. 2011 Aug;15(4):289-94.

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