SUMMARY:

ACOG released a Clinical Practice Guideline with updated evidence-based recommendations for evaluation and treatment of primary and secondary headaches in pregnancy and postpartum, as well as interventions for primary headache prevention

Primary Headaches

Three Primary Headache Disorders Differ in Their Duration, Location, Symptomatology and Temporality

• Migraine
  • Duration: 4 to 72 hours
  • Location: 60% unilateral | 40% bilateral
  • Description and intensity: Pulsating, moderate to severe
  • Associated symptoms: Nausea or vomiting | Photophobia or phonophobia | Aggravated by routine physical activity
• Tension-type
  • Duration: 30 minutes to 7 days
  • Location: Bilateral
  • Description and intensity: Pressing or tightening, mild to moderate
  • Associated symptoms: None
• Cluster
  • Duration: 15 to 180 minutes
  • Location: Unilateral | Orbital, supraorbital, temporal or any combination
  • Description and intensity: Stabbing, severe to excruciating
  • Associated symptoms: Typically none, but may have conjunctival injection, lacrimation, nasal congestion, eyelid edema, facial swelling, may appear restless or agitated

General Background About Primary Headaches

• Primary headaches account for 90% of chronic and recurring headaches in reproductive aged women
• Limited high-quality data around medications for headache prevention
• ACOG recommends a patient-centered, individualized approach with shared-decision making regarding medications for headache prevention

Prevention of Primary Headaches

• Nonpharmacologic
  • Limited data on efficacy | Unlikely to cause harm
  • Lifestyle modifications: Trigger avoidance | Relaxation techniques |Adequate sleep | Stress management | Adequate hydration |Cognitive behavioral therapy | Acupuncture | Biofeedback
• Pharmacologic interventions
  • Limited data on efficacy and safety for use in headache prevention during pregnancy and lactation
  • Indirect safety data for use in other considerations (ex. betablockers and calcium channel blockers as antihypertensives)
  • Medication classes: Antiepileptics | SNRIs |Tricyclics |Betablockers | Calcium channel blockers | Steroids | Benzodiazepines | Antihistamines | Other supplements
  • First line drug classes for prevention with no potential associated maternal or fetal risks
    • Calcium channel blockers: Amlodipine | Nifedipine | Verapamil
    • Antihistamines: Cypropheptadine |Diphenhydramine
  • Some medications require balancing risks and benefits such as
    • Benzodiazepines (e.g., alprazolam): Potential risk for oral cleft and other major birth defects
    • Beta-blockers (e.g. labetalol): Potential risk for CVS anomalies, oral cleft, NTDs and FGR
    • Tricyclic antidepressants (nortryptiline): Potential risk for SGA, major congenital anomalies, CVS anomalies, neonatal convulsions and respiratory distress  
  • Some medications are known to cause harm and should not be used such as
    • Antiepiletics (e.g., valproic acid and topipramate): Potential risk for fetal death, miscarriage, major congenital anomalies
    • ACE inhibitors (e.g., lisinopril): Potential risk for major congenital malformations, cardiac malformations, oligohydramnios
    • CGRP monoclonal antibodies (e.g., galcanezumab): Stop 6 months before pregnancy | Lack of available human data currently    

Secondary Headaches

• Secondary headache disorders are common
  • Most common in postpartum period is musculoskeletal headache

Differential for Secondary Etiologies

• Preeclampsia related
  • Reversible cerebral vasoconstriction (RCVS)
  • Posterior reversible encephalopathy syndrome (PRES)
  • Although preeclampsia is most common, alternative etiologies should be considered with headache and neurologic symptoms especially if altered level of consciousness, vomiting or fever
• Central venous sinus thrombosis (CVST)
  • Constant and nonspecific headache in third trimester or postpartum
  • With or without seizures and focal deficits
• Post dural puncture headache (PDP)
  • Occipito-frontal, postdural headache after regional anesthesia
• Idiopathic intracranial hypertension (IIH)
  • Retro-ocular, frontal headache
  • Visual symptoms
• Carotid artery dissection or subarachnoid hemorrhage
  • Severe refractory “thunderclap” headache
  • Neck pain
  • Focal neurologic deficits
• Pituitary apoplexy
  • Severe headache, sudden visual deficit
  • Possible hypopituitarism
  • Hypotension
• Neoplasm
• Infection
  • Headache with fever, chills, fatigue, shortness of breath

Secondary Headache Investigation

• Screen patients for history of migraine prepregnancy
• If BP >140/90 and >20w0d
  • Evaluate for gestational hypertension and preeclampsia
• If headache intractable, new or different from other headaches with red flags (see below)
  • Brain MR or CT with or without contrast (depending on whether patient is still pregnant or postpartum)
  • Neurology consultation
• If patient is postpartum and regional anesthesia used, consider dural puncture headache and consult anesthesia

Red Flags Warranting Emergent Evaluation

• Rapid onset |” Thunderclap” | Elevated BP | Fever | Third trimester | Focal neurologic deficits | Altered consciousness | Lab abnormalities
  • Timely imaging is important to prevent possible development of neurologic deficits
  • 25% of pregnant patients with acute headache, secondary etiology may be revealed on brain imaging
• When imaging is warranted, ACOG states that “limited availability of MRI in some healthcare settings should not delay assessment and CT should instead be performed in available”

Treatment Options

Primary Headache Treatment

• Recommendations are based on expert opinion and published fetal safety data, often indirectly obtained from studies using the same medication for other maternal indications.
• The following drugs are recommended by ACOG as first line for treatment
  • Acetaminophen
  • Caffeine
  • Diphenhydramine
  • Metoclopramide
  • NSAIDs (ibuprofen, indomethacin, naproxen) use is guided by trimester
    • First trimester: Limit use
    • Second trimester: Balance risks and benefits of administration for ≤48 hours
    • Third trimester: Avoid use
• ACOG suggests cautious use of the following drugs with recommendation to balance risks and benefits
  • Magnesium, IV
  • Methylprednisolone or prednisone
  • Ondansetron
  • Sumatriptan
• The following drugs are not recommended due to potential associated risks
  • Butalbital
  • Codeine
  • Fentanyl
  • Hydrocodone
  • Oxycodone
• The following drugs are not currently recommended due to no published human pregnancy data
  • Lasmiditan
  • Rimegepant
  • Ubrogepant
  • Ergot alkaloids (ergotamine or dihydroergotamine) should be avoided in pregnancy due to potential risk of uterine contractions
• Acute management of primary headaches in OB triage or the ED
  • Careful history of prior headache experience to establish diagnosis of persistent intractable migraine versus a secondary cause
  • History of recent medication use to guide therapy options
  • Assure adequate hydration | Nausea and vomiting are frequent complications of migraines | Fluid replacement may be indicated
  • Comprehensive Metabolic Panel may be helpful if dehydration is suspected and to screen for other etiologies

Secondary Headache Treatment

• Treatment dependent on secondary headache type
  • Preeclampsia: Delivery if unresolved
  • PRES: Urgent antihypertensives and delivery
  • RCVS: Delivery
  • Idiopathic Intracranial Hypertension: Acetazolamide | Serial lumbar punctures
  • PDP: Epidural blood patch
  • CVST: Anticoagulation with adjusted-dose LMWH
  • Pituitary apoplexy: Endoscopic transsphenoidal resection | High-dose hydrocortisone

Stepwise Treatment Approach to Complaint of Headache

Primary Headache

• Combination oral acetaminophen (1000 mg) and caffeine (130 mg)
• If not improved within 60 minutes: Combination IV therapy with metoclopramide 10 mg and diphenhydramine 25 mg
• Can repeat IV therapy in 6 hours if after observation/sleep for several hours, moderate residual headache is present

Secondary Headache

• Consider if no response to treating primary headaches treatment options
  • Single dose of NSAID (oral ibuprofen or indomethacin, IV ketorolac) for resistant headache in the second trimester
  • Sumatriptan, available as injection, nasal spray, oral formulation and subcutaneous injection
  • Magnesium 2 g IV over 10 to 20 min
• May need to admit for continued IV therapy

Lactation

• NSAIDs and acetaminophen are first-line therapy for acute management of primary headache
• Triptans may be used with shared decision making
  • Expert opinion suggests avoiding breastfeeding for 9 to 12 hours after sumatriptan use and after 24 hours following use of other triptans
• Medications containing opioids (codeine, hydrocodone, hydromorphone) should not be used, as they may cause infant sedation
• Ergot alkaloids are not recommended

KEY POINTS:

• Three primary headache disorders (migraine, tension and cluster) account for 90% of chronic headaches
• A patient-centered, individualized approach with shared-decision making regarding medications for headache prevention is recommended due to limited high-quality data
• Evaluation for primary headaches includes screening for pre-pregnancy history and for secondary headaches includes history, physical exam and other tests including imaging and consultant evaluation as appropriate
• Acute headache treatment includes medications for home use and treatment of intractable headache in triage of the emergency department

Learn More – Primary Sources:

ACOG Clinical Practice Guideline 3: Headaches in Pregnancy and Postpartum

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