Headache and pregnancy: a systematic review

Abstract

This systematic review summarizes the existing data on headache and pregnancy with a scope on clinical headache phenotypes, treatment of headaches in pregnancy and effects of headache medications on the child during pregnancy and breastfeeding, headache related complications, and diagnostics of headache in pregnancy. Headache during pregnancy can be both primary and secondary, and in the last case can be a symptom of a life-threatening condition. The most common secondary headaches are stroke, cerebral venous thrombosis, subarachnoid hemorrhage, pituitary tumor, choriocarcinoma, eclampsia, preeclampsia, idiopathic intracranial hypertension, and reversible cerebral vasoconstriction syndrome. Migraine is a risk factor for pregnancy complications, particularly vascular events. Data regarding other primary headache conditions are still scarce. Early diagnostics of the disease manifested by headache is important for mother and fetus life. It is especially important to identify “red flag symptoms” suggesting that headache is a symptom of a serious disease. In order to exclude a secondary headache additional studies can be necessary: electroencephalography, ultrasound of the vessels of the head and neck, brain MRI and MR angiography with contrast ophthalmoscopy and lumbar puncture. During pregnancy and breastfeeding the preferred therapeutic strategy for the treatment of primary headaches should always be a non-pharmacological one. Treatment should not be postponed as an undermanaged headache can lead to stress, sleep deprivation, depression and poor nutritional intake that in turn can have negative consequences for both mother and baby. Therefore, if non-pharmacological interventions seem inadequate, a well-considered choice should be made concerning the use of medication, taking into account all the benefits and possible risks.

Medication Use and Pain Management in Pregnancy: A Critical Review

“…Primary headaches account for the majority of headaches in pregnancy . The most common primary headaches are tension‐type headaches and migraines, which generally improve during pregnancy . Relief of pre‐existing headaches during pregnancy is more common than new onset of headache during pregnancy .…”

“…Pregnancy is a risk factor for a secondary headache disorder from pathologies such as cerebral venous thrombosis, pre‐eclampsia, posterior reversible encephalopathy syndrome, and both ischemic and hemorrhagic stroke . When a pregnant woman presents with a headache that is severe, or that has changed in nature from the usual headache, the priority must be to distinguish primary causes from more serious secondary causes .…”

Imaging in pregnancy

“…MRI enables the visualisation of deep soft tissue structures and does not rely on the use of ionising radiation . MRI is useful for assessing a variety of medical conditions – for example, posterior reversible encephalopathy syndrome, cerebral venous thrombosis, acute appendicitis, Crohn's disease and suspected morbidly adherent placenta . Antenatal MRI is increasingly used to further evaluate structural fetal anomalies, including cranial lesions (ventriculomegaly, agenesis of the corpus callosum, gyral or sulcation pattern), neural tube defects, congenital pulmonary airway malformations, congenital diaphragmatic hernia and cardiovascular anomalies (teratoma, rhabdomyoma or vascular abnormalities) …”

“…However, clinicians must be alert to causes of secondary headache in pregnancy, including pre‐eclampsia, posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome and acute arterial hypertension. Other causes of secondary headache in pregnancy include cerebral venous thrombosis, intracranial haemorrhage, subarachnoid haemorrhage, ischaemic stroke, pituitary adenoma and malignancy . Box 1 summarises red flag symptoms associated with headache that require further investigation in pregnancy …”

“…Following detailed history taking and clinical assessment, women with focal neurological deficits or signs of raised intracranial pressure (papilloedema, ocular palsy, hypertension) should be referred for urgent intracranial imaging . Table summarises the intracranial imaging techniques that can be employed to investigate underlying causes of headache in pregnancy . Fetal exposure following CT of the maternal head is estimated at 0.001–0.01 mGy (Table ).…”