Headache

Maternal risks

Headache during pregnancy are extremely common. The most common categories are migraine and tension-type. Although a new-onset headache during pregnancy is most likely either a migraine or tension-type, it may be the first manifestation of an intracranial process that needs immediate attention. Such conditions include aneurysm rupture, AVM, intracranial hypertension, cerebrel ischemia, cerebrovenous thrombosis, meningitis, sinusitis, and intracranial masses. In addition, benign intracranial hypertension or psudotumor cerebri may be seen with pregnancy, but it is uncommon. Patients receiving spinal or epidural analgesia or anasthesia may experience a spinal headache during the postpartum period.

Evaluation of the pregnant patient with headache represents a clinical challenge. The ailment’s prevalence and typically benign nature make it desirable to minimize costs by limiting diagnostic testing while being certain to promptly diagnose uncommon but more serious conditions. The medical history suggestive of migraine headache, a normal neurologic examination, and resolution with simple measures, the patient may be followed clinically. If a new-onset headache severe enough to justify an emergency room visit or a preexiting condition becomes progressively worse, an “aura” is present, or a neurologic deficit is identified, diagnostic evaluation is indicated.

Migraine

Maternal and Fetal Risk

Migraines can be subdivided inti those with or without an aura. The aura is described as a presence of transient neurologic signs or symptoms before, during, or even after the headache. The pain is often associated with nause, vomiting, and photophobia. Sleep often provides relief. As with headaches in general during gestation, the course of migraines is variable. A decrease in pregnancy is seen in 50% to 80% of women, particulary in the third trimester. Those patients experiencing migraines associated with menstruation are especially likely to show improvement. The headache tend to worsen postpartum, with as many as 40% of patients complaining of pain during this time. Migraine recurred during the puerperium in 4,5% of patients, however,

and an aura may initially appear during this time period. No demonstated adverse fetal outcome is associated with migraines.

Management options

Prenatal, Labor, Delivery, and Postnatal

A carefully obtained histori and physical exam are essential. With a prior personal or family history of migraine and a typical presentation, no further investigation is needed. New-onset migraines repressent a diagnosis of exclusion. In the abscence of a past history or with focal neurologic findings, neuroimaging studies such as brain CT or MRI are indiciated. It is desirable to minimize abdominla and pelvic exposure to x-rays and avoid