Headache in Pregnancy

Aka: Headache in Pregnancy, Migraine in Pregnancy, Antepartum Headache, Postpartum Headache

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II. Types: Primary Headaches

  1. Chronic Daily Headache
  2. Tension Headache
  3. Migraine Headache
    1. Migraines improve with pregnancy in up to 70-80% of patients by second trimester
    2. Less commonly (8%) will have worsening of chronic Migraines during pregnancy
    3. Uncommonly (2%) of first Migraines occur in first trimester (associated with aura)

III. Differential Diagnosis: Secondary Headaches in Antepartum Period

  1. See Headache Causes
  2. See Headache Red Flags
  3. Pregnancy Induced Hypertension (Preeclampsia)
    1. Consider after 20 weeks gestation until 6 weeks postpartum
    2. Severe, new onset bilateral Headache with Blurred Vision and Hypertension
  4. Posterior Reversible Encephalopathy Syndrome (PRES)
    1. Severely hypertensive patients (e.g. Severe Preeclampsia), especially in the Postpartum Period
    2. Presents with dull throbbing Headache, confusion, Seizures, Vision Loss
  5. Reversible Cerebral Vasoconstriction Syndrome (RCVS)
    1. Sudden fluctuating Headache, confusion, transient blindness
    2. Increased risk with Preeclampsia
  6. Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)
    1. Retroocular frontal Headache with visual changes
  7. Cerebral Venous Thrombosis (Cortical Vein Thrombosis)
    1. Complicates 1 in 2500 pregnancies (esp. third trimester or postpartum, phospholipid Antibody syndrome)
    2. Findings may include Increased Intracranial Pressure, focal neurologic deficits, Seizures
  8. Subarachnoid Hemorrhage
    1. May complicate Preeclampsia or HELLP Syndrome and presents with Thunderclap Headache
  9. Other causes
    1. See Headache Causes
    2. Cervical Artery Dissection
    3. Thrombotic Thrombocytopenic Purpura
    4. Acute infections
      1. Meningitis
      2. Encephalitis
      3. Legionnaires Disease
      4. Borrelia miyamotoi
      5. Neurocysticercosis (esp. Immigrants from endemic regions)

IV. Differential Diagnosis: Secondary Headaches in Postpartum Period (Postpartum Headache)

  1. See Headache for other causes
  2. See Headache Red Flags
  3. Pregnancy Induced Hypertension (Preeclampsia)
    1. May occur up to 6 weeks after delivery
    2. Critical diagnosis commonly missed in postpartum patients (Magnesium IV is drug of choice)
    3. Evaluate for Hypertension and Proteinuria (or alternative criteria) in all Postpartum Headache patients
  4. Posterior Reversible Encephalopathy Syndrome (PRES)
  5. Reversible Cerebral Vasoconstriction Syndrome
    1. Thunderclap Headache
  6. Post-epidural Headache
    1. Spinal Headache (Post-Lumbar puncture headache)
    2. Pneumocephalus
  7. Cerebral Venous Thrombosis (Cortical Vein Thrombosis)
  8. Spontaneous Subarachnoid Hemorrhage
  9. Meningitis
  10. Pituitary Apoplexy (Hemorrhagic infarction of the Pituitary Gland)
    1. Risks include peripartum state and history of Pituitary Microadenoma
    2. Presents with sudden onset severe Headache, bitemporal Hemianopsia, Hypotension

V. Management

  1. See Nonpharmacologic Headache Treatment
  2. See Headache Medications in Pregnancy
  3. See Headache Medications in Lactation

VI. References

  1. Jhun, Weinstock and Jaque in Herbert (2017) EM:Rap 17(1): 14-5
  2. Johnson (2004) Prim Care Office Pract 31:417-28
  3. Swaminathan and Marcolini (2024) EM:Rap, 11/4/2024
  4. (2022) Obstet Gynecol 139(5):944-72 +PMID: 35576364 [PubMed]
  5. Gregory (2018) Am Fam Physician 98(9): 595-602 [PubMed]
  6. Silberstein (2004) Neurol Clin 22:727-56 [PubMed]

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