Headaches in Pregnancy

Introduction

Headaches in Pregnancy time are not just an annoyance but also additionally concerning especially if they are of new onset.

A new onset headache some times warrants an investigation but during pregnancy not all investigations are safe e.g. x ray based procedures like plain x-ray or CT scan etc. They are generally contraindicated because of the harmful effect of the radiation to the fetus. Even MRI, which actually doesn’t use the harmful ionizing radiation, is relatively contraindicated especially in the first trimester of pregnancy.

So a new onset headache is concerning to both the patient and her doctors because of the above reason.

Another constraint during pregnancy is with the usage of medications (in this case the headache medications) and these issues are discussed again below.

Some examples of headaches in pregnancy period

• Migraine-headache
• Tension-headache
• Sinus-headache
• Cluster-headache (more common in men)
• Pregnancy hypertension (pre-eclampsia/eclampsia) induced-headache
• Thrombosis of the venous sinuses or cortical veins of the brain
• Tumors
• Abscesses
• Vascular malformations (e.g. AVM etc)
• Cerebral (brain) aneurysms etc.

The good news is that the majority of the headaches occurring during pregnancy period are not serious in nature. Well the headache might bother the patient a lot, but there may not be an underlying serious pathology most of the times, that is the point. Many of these headaches are assumed to be related with the hormonal changes taking place in the body like increased estrogen levels. Migraine & tension type headaches are common during pregnancy, but they are common in women during the reproductive years any way.

If patient has history of such headaches and the recent episodes are similar to her prior-to-pregnancy episodes then it is reassuring because there may not be any underlying serious pathologies to explain the headache, also no radiological investigations are necessary. However if the episodes are new onset and/or different type compared to previous episodes then it is definitely concerning.

Work up for Headaches in Pregnancy period

If patient’s blood pressure is high then we may be dealing with pregnancy induced hypertension and related conditions like pre-eclampsia or eclampsia etc.

If blood pressure is ok plus the episodes do not appear to be primary headache syndromes like migraine etc, then a serious decision needs to be undertaken by the physician involved in her care about the radiological investigations.

If investigations seems to be mandatory then to go ahead with them; if conditions like brain tumor, abscess, vascular malformations etc are suspected then wait & watch policy could be dangerous to the mother’s health.

A condition that occurs with higher incidence during pregnancy is the clot formation in the venous system of the brain (the dural venous sinuses and cortical veins). This may be related with estrogen; and dehydration, fever etc might contribute.

If CT is done then abdominal shielding with thick lead blankets may help in preventing radiation exposure to the fetus. Although MRI seems to be preferable to CT however its safety during pregnancy has not been confirmed yet. It is to be avoided especially during the first trimester. MRV (magnetic resonance venography) may be needed for clot in the venous system. Rarely an angiogram is necessary especially if AVM or cerebral aneurysm is suspected.

Treatment for Headaches in Pregnancy period

This is the second challenging thing for the physician involved in the care of a pregnant lady with headaches.

Majority of the medications are to be avoided during pregnancy because they may cause harmful effect to the fetus, and headache medications are not exceptions unfortunately. Patients are advised to take medications only if they feel they are absolutely necessary. Small doses of acetaminophen (Tylenol) can be given. There is also a tendency for some doctors to give small doses of narcotic pain killers like Tylenol#3 (Tylenol with codeine) when headache is unbearable.

If serious pathologies as discussed above are found then they are treated appropriately.

Pregnancy induced hypertension/preeclampsia/eclampsia are treated with medications to lower the blood pressure, and generally magnesium if seizures are present.



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