Headache Management in Pregnancy Headache Diagnosis Management in Evaluation Pregnancy Pharmacological options Injections and neuromodulation Alternative options Morris Levin, MD Professor of Neurology, UCSF Director, UCSF Headache Center 1. New 1 st trimester 2. Preexisting headaches headaches worsening in pregnancy 29 year old G1 woman LMP 8 weeks ago 31 year old woman with migraines with aura began having frequent severe HAs with since late teens; had infrequent headaches until early in this 3 rd pregnancy now in 2 nd nausea, photosensitivity and phonosensitivity about 1 month ago. She trimester. “My mother says that is because denies having migraines or other this is a boy”. headaches in the past but her mother There is some baseline nausea but during and aunt have migraine. headaches this worsens, and she has had Acetaminophen is not helpful – “I just more pronounced visual auras have to ride them out”
3. New late pregnancy HA Women’s headaches Migraine is 3x more common in women (18%) 22 year old pregnant woman at 38 weeks was than men (6%), with the highest prevalence in admitted last night with a severe holocranial peak reproductive years: ~30% of women headache. She had several milder headaches 85% of Chronic Migraine sufferers are women earlier in this her first pregnancy. Menses, pregnancy, menopause are all times of She has no history of migraine or other significant change in migraine headaches, but does recall several family Most neurologists are not trained in hormonal members with headaches. management of menstrual migraines or Exam is remarkable only for intense migraines during pregnancy; and most photophobia and unwillingness to move at all. gynecologists are not trained in migraine treatment Migraine Prevalence Married life Death of Dating husbands “I used to have a headache. But he went away.”
Migraine course in pregnancy Migraine-related pregnancy risks Retrospec review in Taiwan - 4911 preg women with migraine c/w >24,000 controls - Migraine seems to be risk of preterm delivery Migraine tends to improve during pregnancy [1], and preechlampsia (OR’s 1.2, 1.4) [1] BUT some women experience an increase in Prospective cohort study in Italy also demonstrated that preterm birth occurred at a higher rate in those with a history of headache frequency or intensity [2], particularly in the first (OR: 2.74) [3] trimester when human chorionic gonadotropin Co-morbid mood disorders double those risks [2] levels are falling. Increased risk of overall hypertensive disorders including gestational hypertension and preeclampsia compared to non- When improvement is not seen after this point, migraine sufferers - OR 2.85 [4] migraine is likely to continue throughout the Increased risk of ischemic stroke in pregnancy (OR range 7.9 to pregnancy and extend into the postpartum 30.7), acute myocardial infarction and heart disease (OR 4.9), and thromboembolic events (deep venous thrombosis OR 2.4 [5 ] period [3]. 1. Chen HM, et al. Increased risk of adverse pregnancy outcomes for women with migraines: a nationwide population-based study. Cephalalgia . 2010;30(4):433–8 1. Granella F, Sances G, Pucci E, Nappi RE, GhiottoN, et al.Migrainewith aura and reproductive life 2. Marozio L, et al. Headache and adverse pregnancy outcomes. Eur J Obstet Gynecol Reprod Biol. 2012;161(2):140–3 events: a case control study.Cephalalgia. 2000;20:701–7. 3. Cripe, S.M, et al 2011. Risk of preterm delivery and hypertensive disorders of pregnancy in relation to maternal co ‐ morbid mood and 2. Maggioni F, Alessi C, Maggino T, Zanchin G. Headache during pregnancy. Cephalalgia. 1997;17:765–9 migraine disorders during pregnancy. Paediatric and perinatal epidemiology , 25 : 116-123. 3. Sances G, Granella F, Nappi RE, FignonA, Ghiotto N, et al. Courseof migraine during pregnancy and 4. Facchinetti F,, et al. Migraine is a risk factor for hypertensive disorders in pregnancy. Cephalalgia 2009;29:286–92. 5. Wabnitz A, Bushnell C. Migraine, cardiovascular disease, and stroke during pregnancy: systematic review of the literature. postpartum: a prospective study.Cephalalgia. 2003;23:197–205. Cephalalgia. 2015;35(2):132–9. Migraine pregnancy risks 1. Migraine without aura Sleep disturbances are inevitable during Headache attacks lasting 4-72 h (untreated or pregnancy and are risks for both headaches unsuccessfully treated) and mood disorders Headache has 2 of the following 1. unilateral location Depression and anxiety are more likely in 2. pulsating quality pregnant women with migraine* 3. moderate or severe pain intensity In migraine, 50% of pregnancies are unplanned 4. aggravation by or causing avoidance of routine physical activity ( eg , walking, climbing stairs) During headache 1 of the following: 1. nausea and/or vomiting 2. photophobia and phonophobia ICHD 3 *Orta, OR, et al. Depression, anxiety and stress among pregnant migraineurs in a pacific northwest cohort. J Affect Disord 2014, 172:390-6
1.2 Migraine with aura 2. Tension type HA 2 of the following 4 characteristics: 1 of the following fully reversible aura symptoms: 1. bilateral location 1. visual; 2. sensory; 3. speech and/or language; 2. pressing or tightening (non-pulsating) quality 4. motor ; 5. brainstem; 6. retinal 2 of the following 4 characteristics: 3. mild or moderate intensity 1. 1 aura symptom spreads gradually over ≥5 min, 4. not aggravated by routine physical activity and/or 2 symptoms occur in succession Both of the following: 1. no nausea or vomiting 2. each aura symptom 5-60 min 3. 1 aura symptom is unilateral 2. no more than one of photophobia or phonophobia 4. aura accompanied or followed in <60 min by headache Diagnosing Primary International Classification of Headaches – Headache Disorders 2018 The essentials Primary HA 1. Migraine 2. Tension-type HA Migraine - unilat, throbbing, female 3:1, 3. Cluster headaches relatives (TAC) 4. Exertional and other headaches nausea, +/- aura Secondary HA 5. Posttraumatic Tension-type HA – bilateral, milder, 6. Vascular disease no nausea, no aura 7. Abnormal ICP, Neoplasm, Hydrocephalus 8. Substances Cluster - Unilateral, male predom, brief, 9. CNS infection 10. Metabolic recurring in cycles 11. Cervicogenic, Eyes, Sinuses, Jaw ICHD 3 12. Psychiatric HA 13. Neuralgias
Secondary Headaches - Secondary Headaches - When to look for them in Pregnant pt When to look for them in Pregnant pt Unusual headache for patient Unusual headache for patient Change in personality, cognition, neuro exam Change in personality, cognition, neuro exam Sudden, Effort induced or Positional Sudden, Effort induced or Positional Febrile or Systemic illness - AIDS, Cancer Febrile or Systemic illness - AIDS, Cancer Key headache ddx in pregnancy New frequent long-lasting HAs 1 st /2 nd trimester Migraine 5-year record review of 140 pregnant women seeking treatment Intracranial hypertension for acute headache via emergency department or labor/delivery/antepartum units revealed that: Cerebral venous thrombosis Idiopathic Intracranial Hypertension 65 % had primary headache disorders (59 % were migraine) 35 % presented with secondary headache disorders Late emergence of HAs including postpartum “Hence the importance of neuroimaging and close monitoring in this population”. Eclampsia (migraineurs seem to be at higher risk) Intracranial hemorrhages Reversible Cerebral Vasoconstriction Syndrome (RCVS) Robbins MS, FarmakidisC, Dayal AK, Lipton RB. Acute headache diagnosis in pregnant women: a hospital- Intracranial hypotension (CSF leak) based study. Neurology. 2015;85(12):1024–30.
Evaluation of HA in Pregnancy Increased intracranial pressure CT poses minimal risk to fetus, but Iodinated • Pregnant women are at risk for cerebral contrast should be avoided as it may suppress venous thrombosis and idiopathic intracranial fetal thyroid hypertension. MRI considered safer, and is more useful than non-c CT • If there are any signs of increased intracranial pressure MRI without gadolinium and MRV are indicated. Gadolinium does cross the BBB and animal studies suggest potential adverse fetal effects, • If imaging is normal, but there are signs of intracranial so avoid if possible hypertension, lumbar puncture should be performed even Lumbar puncture (LP) safe and is necessary in though intracranial hypertension is very unlikely without suspected meningitis, subarachnoid papilledema or other symptoms such as visual hemorrhage (SAH), or idiopathic intracranial obscurations, pulsatile tinnitus, double vision, or neck or hypertension (IIH). back pain Headache attributed to IIH Idiopathic intracranial hypertension Pseudotumor Cerebri MRI findings include empty sella, tortuosity of the optic A. Any headache fulfilling criterion C nerves with dilation of the perioptic nerve subarachnoid B. Idiopathic intracranial hypertension (IIH) space, flattening of the posterior globe, and small ventricles diagnosed, with CSF pressure >250 mm CSF C.Evidence of causation demonstrated by ≥2 of the following: 1. headache has developed in temporal relation to IIH, or led to its discovery 2. headache is relieved by reducing intracranial hypertension 3. headache is aggravated in temporal relation to increase in intracranial pressure D.Not better accounted for by another ICHD-3 diagnosis
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