Headache in Pregnancy: An Approach to Emergency Department Evaluation and Management

Abstract

Headache is a common presenting complaint in the emergency department. The differential diagnosis is broad and includes benign primary causes as well as ominous secondary causes. The diagnosis and management of headache in the pregnant patient presents several challenges. There are important unique considerations regarding the differential diagnosis, imaging options, and medical management. Physiologic changes induced by pregnancy increase the risk of cerebral venous thrombosis, dissection, and pituitary apoplexy. Preeclampsia, a serious condition unique to pregnancy, must also be considered. A high index of suspicion for carbon monoxide toxicity should be maintained. Primary headaches should be a diagnosis of exclusion. When advanced imaging is indicated, magnetic resonance imaging (MRI) should be used, if available, to reduce radiation exposure. Contrast agents should be avoided unless absolutely necessary. Medical therapy should be selected with careful consideration of adverse fetal effects. Herein, we present a review of the literature and discuss an approach to the evaluation and management of headache in pregnancy

Wisely Evaluating and Managing Headaches

“…These non‐specific medications are often used because there is uncertainty in the diagnosis or because a patient's full health history is unknown, and hence there is reluctance to prescribe a vasoconstrictive agent such as a triptan. However, the treatment of headache disorders with opiates or barbiturates can lead to interference with the effectiveness of anti‐migraine‐specific treatments, medication overuse, and worsening of a primary headache disorder, and their use risks patient dependence on potentially harmful prescription medications …”

Akuter Kopfschmerz als Notfallsymptom

“…In der Schwangerschaft ist eine native MRT-Untersuchung die zu bevorzugende Untersuchungsmethode, wobei auch eine native Computertomografie mit einer fetalen Strahlendosis von 1 rad relativ sicher ist und nur zu einer allenfalls geringen Zunahme kindlicher Leukämien führen dürfte [26]. Die Anwendung Jod-oder Gadolinium-haltiger Kontrastmittel sollte dagegen auf vitale Indikationen beschränkt bleiben.…”

“…Bei rund 20 % der Schwangeren ist eine Zunahme oder ein Neuauftreten primärer Kopfschmerzen beobachtbar [26]. In der Schwangerschaft stellen 15-55 % der Kopfschmerzen sekundäre Formen dar.…”

“…Kopfschmerzen post partum (Inzidenz 30-40 %) sind in bis zu 70 % sekundäre, abklärungspflichtige Kopfschmerzen, am häufigsten als Ausdruck postpunktioneller Kopfschmerzen, einer Präeklampsie oder zerebrovaskulärer Ursachen (zusammengefasst in der folgenden Übersicht). Eine Präeklampsie mit blutdruckabhängigen, bilateral-pulsierenden Kopf-schmerzen kann bis zu 4 Wochen nach der Entbindung beginnen und wird akut mit Nifedipin, Urapidil und Magnesium behandelt [26].…”

Presenting Symptoms of Pituitary Apoplexy

“…18,19 In gestation, maternal PA can appear at any time [20][21][22] but usually happens perinatally. 23,24 Purpose PA is a rare and potentially life-threatening condition with a highly variable clinical presentation 25,26 that is typically abrupt and impressive. 27 Its severity ranges from headache to coma, 28 and symptoms also vary in duration.…”