Book Reading

Fetomaternal SubDiv.

Headache
in pregnancy

Presentator
dr. Ukhron Novansyah
Moderator
dr. H. Nuswil Bernolian, SpOG(K)

Key Points...
Most causes of headache in pregnancy due to
migraine (18%) or tension-type headache.
New-onset headache in pregnancy requires a
thorough neurological evaluation
neuroradiographic studies and/or cerebrospinal
fluid (CSF) analysis.
worrisome disorders that cause headache in
pregnant women subarachnoid hemorrhage,
stroke, pituitary tumor or apoplexy, and cerebral
venous thrombosis.

 Education about avoiding specific food, caffeine

and alcohol triggers for migraine may reduce the
need for both preventive and acute medications.
Pregnant patients with headache should avoid
skipping meals, should regularize their sleep and
exercise habits, and consider yoga, meditation,
or biofeedback as an adjunctive migraine
preventive modality.

 Certain acute and preventive medication can be

used with caution in pregnancy; most are not
absolutely contraindicated.
Most patients with migraine without aura, and
many with migraine with aura, improve during
pregnancy, particularly during the second and
third trimester.

For acute treatment of primary headache,

first choice during all trimesters Acetaminophen,
alone (preferably), or with codeine (for refractory
headache
Safe and well tolerated but should be avoided after 28
weeks Naproxen and ibuprofen
Severe unrelenting migraine responds well to parenteral
antiemetics metaclopramide and prochlorperazine.
Prophylactic medication Propranolol can be
considered

Background / Epidemiology...
The relationship between headache and
pregnancy is of concern for two reasons:
1. Primary headache disorders (migraine or
tension-type headaches)
2. Impact of headache in women affected by
reproductive life events

 Prevalence is 18% in women in the United States

a peak incidence following menarche in young
girls (reproductive age of 20 to 50), 6 % in men
Exacerbated by menses, influenced by hormonal
contraception and replacement therapy,
menopause.
Particularly migraine without aura, generally
improves with pregnancy and worsens in the
postpartum period.

Diagnosis...
Diagnostic criteria the International headache
Society

Diagnostic Considerations for Headache in

Pregnancy
Primary causes of headache:
Migraine with and without aura
Tension-type headache
Trigeminal autonomic cephlagias (cluster
headache)
Cough headache

Diagnostic Considerations for Headache in

Pregnancy
Secondary causes of headache (because of another, often
ominous, disorder):
Cortical venous thrombosis or cranial sinus thrombosis
Subarachnoid hemorrhage
Preeclampsia or eclampsia associated with elevated blood
pressure [associated with reversible cerebral vasospastic
syndrome (RCVS)]
Stroke
Idiopathic intracranial hypertension (pseudotumor cerebri)
Pituitary tumor and pituitary apoplexy
Headache associated with trauma to the head or neck, or to
infection or disease of the meninges, sinuses, eyes, or ears

Red flags suggesting a secondary (ominous) headache:

Sudden-onset (thunderclap) headache
Secondary risk factors (HIV, systemic cancer)
Headache associated with systemic symptoms (fever,
weight loss, meningeal signs, papilledema) or focal
neurologic signs (confusion, impaired alertness, or
incoordination)
New, different, or progressively worsening headache
Positional headache that occurs only in the upright
posture and is relieved with recumbency (CSF leak)

Epidemilogy / Pathophysiology...
18% of women and 6% of men had a migraine
headache, but nearly half of these patients
remain undiagnosed.
Approximately 40% of women suffered from
episodic or chronic tension-type headache
Improves during pregnancy first migraine can
occur during pregnancy in the first trimester.

 Migraine associated with elevated and sustained

levels of plasma estrogens are felt to be protective
during pregnancy and the fall in estrogen at the
onset of menses a factor in menstrually.
Estrogens are known to increase pain thresholds
in animal studies and endogenous opioids also
increase as pregnancy progresses.
Migraine often recurs postpartum, usually within
three to six days

 The pathophysiology of migraine is complex

Headache head pain ; The meninges,
proximal cerebral blood vessels, and venous
sinuses are pain sensitive.
Therefore it is not surprising that subarachnoid
hemorrhage from a ruptured aneurysm, or vessel
distension from a venous thrombosis, would
produce head pain.

 The migraine aura cortical spreading

depression (CSD).
CSD is a spreading decrease in electrical activity
that moves across the cerebral cortex at 2 to 3
mm/min.
CSD characterized by shifts in cortical steady state
potential, transient increases in potassium, nitric
oxide, and glutamate, and transient increases in
CBF, followed by sustained decreases.

From MRI studies..

that a period of hyperemia precedes the oligemia
present during the migraine aura and the headache
itself can begin before hyperemia, while blood flow
in the cerebral cortex is still reduced.
Headache probably results from activation of
meningeal and blood vessel nociceptors combined
with a change in central pain modulation.
Headache and its associated neurovascular changes
are subserved by the trigeminal system.

Genetics...
Migraine is a group of familial disorders with a genetic
component.
Familial hemiplegic migraine (FHM) is a group of autosomal
dominant disorders associated with attacks of migraine, with and
without aura, and hemiparesis.
FHM1 accounts for approximately two-thirds of cases and is due to
at least 10 different missense mutations in the CACNA1A gene,
which codes for the a1-subunit of a voltage dependent P/Q Ca2
channel.
FHM2 results from a new mutation in the a2-subunit of the Na/K
pump. FHM3 is due to a missense mutation in gene SCN1A
(Gln1489Lys), which encodes an a1-subunit of a neuronal voltagegated Na channel (Nav1.1)

Pregnancy Consideration
Effect of Pregnancy on the Disorder...
Women with migraine improve during
pregnancy first trimester,
Women without aura more commonly than
women with aura, generally by the second and
third trimester.
Women whose migraines began during the
menarche and those with menstrually associated
migraine are more likely to have headaches
precede during pregnancy

Effect of the Disorder on Pregnancy...

Some study said, Its have an increased incidence
of teratogenicity, toxemia, stillbirths, or
miscarriage
One study from Denmark reported that women
with migraine had a higher incidence of low-birthweight infants
A new study from Taiwan found that women with
migraines were at increased risk of having lowbirthweight preterm babies, preeclampsia, and
delivery by, cesarean

Management
Evaluation of Headache in Pregnancy...
Headache in pregnancy should be evaluated in
the same manner as any other time, with the
awareness of specific disorders that are more
frequent or only occur with pregnancy.
Headache that presents in a sudden
(thunderclap) fashion subarachnoid
hemorrhage, particularly if associated with a
change in consciousness or focal neurologic
signs

 Sudden headache can also accompany

preeclampsia (consider RCVS) or pituitary
apoplexy.
Venous or sinus thrombosis, associated with the
puerperium, can present with seizure,
precipitous headache, vomiting or focal signs,
and, if intracranial pressure is elevated,
papilledema

 Head CT and MRI are safe in pregnancy

Gadolinium used as a contrast agent for MRI
scanning, does cross the placenta. Safely used by
ESR
Lumbar puncture to diagnose meningitis or
hemorrhage may be delayed until CT of the brain
without contrast is obtained to avoid the risk of
herniation if a mass, or cerebral edema, is
suspected

Acute Therapy for Headache...

Acute migraine treatments in nonpregnant
women include simple analgesics
(acetominophen, aspirin), nonsteroidal antiinflammatory drugs (NSAIDs), opioids, ergot
alkaloids, isometheptene caffeine-barbiturate
combinations, and triptans
In pregnancy..

Particularly poignant as many women,

unknowingly pregnant, will have used acute
medications to treat migraine or tension-type
headache in the very early days or weeks after
conception

 Acetaminophen (FDA B), drug most commonly

taken during pregnancy. no evidence of any
teratogenic effect
Other drugs (FDA B) : caffeine, ibuprofen,
indomethacin, and naproxen
Other drugs (FDA D) : ibuprofen, indomethacin,
and naproxen at the end of the third trimester
Aspirin (FDA C; D)
Meperidine and morphine (FDA C), but their
use should be restricted late in pregnancy

 Prednisone and dexamethasone (FDA C),

which can be used to treat status migrainosus
Ergotamine and dihydroergotamine (FDA
X), should be avoided in pregnant women.
Ergots are abortifacients and have been shown
to cause fetal distress and birth defects

 metaclopramide, chlorpromazine, and

prochlorperazine, safe and effective
parenterally, in addition to the nausea and
vomiting that can accompany migraine,
Intravenous or intramuscular antiemetics, with
fluid replacement, are very effective in aborting
status migrainosus or severe headache

 Triptans (FDA C) are 5-HT 1B/1D receptor

agonists that are effective in treating migraine
headache and the accompanying symptoms of
photosensitivity, nausea, and vomiting
Study of Triptan (Sumatriptan and Naratriptan)
failed to show a signal for a substantial increase
in the risk of all major birth defects following
prenatal not recommended for pregnant
migraineurs

Headache Prophylaxis in Pregnancy...

Clinicians should be encouraged to treat headaches
in early pregnancy with acute medications such as
acetominophen, or low doses of codeine
Preventive therapy should be reserved for women
whose headaches continue to worsen throughout
pregnancy.
Nonpharmacologic therapies should be initiated
first Relaxation training and thermal
biofeedback, combined cognitive behavioral
therapies

 Propranolol , the safest drug to use in later

pregnancy as a preventive for headache, as it is not
known to have teratogenic effect
Verapamil (calcium channel blocker), may also
be beneficial
Valproic acid, should be avoided for headache
prophylaxis causing neural tube defects.
Topiramate and gabapentin, should be
restricted for headache prophylaxis potential
association with fetal defects

 Education about avoiding specific food, caffeine

and alcohol triggers for migraine may reduce the
need for both preventive and acute medications.
Pregnant patients with headache should avoid
skipping meals, should regularize their sleep and
exercise habits, and consider yoga, meditation,
or biofeedback as an adjunctive migraine
preventive modality.

 Thank you ..