Headaches in Pregnancy and the Puerperium - UPMC [PDF]

Secondary. – Migraine. • Post-partum headaches ... Post-partum headaches. – 40% of post-partum women report headac

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Headaches in Pregnancy and the Puerperium

Robert Kaniecki, MD Director, UPMC Headache Center Assistant Professor of Neurology University of Pittsburgh

Headaches in Pregnancy and the Puerperium • Headaches in pregnancy – Secondary – Migraine

• Post-partum headaches

Headaches in Pregnancy and the Puerperium • Headaches in pregnancy – 5% affected by new headache or headache type

• Post-partum headaches – 40% of post-partum women report headaches

Spierings et al. Neurologist 2016; 21:1-7.

Headache Classification Primary Headaches • • • •

Migraine Tension-type Cluster Other primary headaches

ICDH-3 beta Cephalalgia 2013;33:609-828 4

Secondary Headaches • Trauma • Vascular disorders • Non-vascular intracranial disorder • Substances/withdrawal • Infection • Disorder of homeostasis • Disorder of extracranial structures • Psychiatric disorder • Cranial neuralgia

Headaches in Pregnancy Secondary Headaches

Primary

Secondary

Headache Diagnosis

Pregnancy Considerations Primary Headaches • Migraine • Tension-type

7

Secondary Headaches • • • • • • • •

Preeclampsia/eclampsia RCVS Intracranial hemorrhage IIH Intracranial tumor Venous/sinus thrombosis Stroke Pituitary apoplexy

Clinical Headache Presentations • Secondary headaches: 1-3% • Migraine: 94-95% • Other primary headache syndromes: 3-4%

Clinical Headache Presentations • Secondary headaches: 1-3% • Migraine: 94-95% • Other primary headache syndromes: 3-4% • But pregnant and post-partum situations raise the stakes – 35% of acute headache presentations are secondary

Robbins et al. Neurology 2015;85:1024-1030

Profiling Secondary Headache – First/worst headache – Abrupt onset headache – Progression or fundamental change in pattern – New headache in those 50yo – New headache in high-risk clinical settings – Headache with syncope or seizure – Headache triggered by exertion/valsalva/sex – Neurologic symptoms >1hour in duration – Abnormal general or neurological examination

10

Workup of Potential Secondary Headache • Neuroimaging – ED/Acute – Head CT – Outpatient/subacute – MRI – Low threshold for MRA and MRV

• Special settings – LP

• No role for EEG

11

Diagnostic Procedures

CT contrast FDA class B, gadolinium class C Digre. Clin Obstet Gynecol 2013;56:317-329

Idiopathic Intracranial Hypertension

Preeclampsia

Skliut. Curr Pain Headache Rep 2016;20:56

RCVS

Skliut. Curr Pain Headache Rep 2016;20:56

Lymphocytic Hypophysitis

Skliut. Curr Pain Headache Rep 2016;20:56

Headaches in Pregnancy Migraine

Migraine Headache

30 25

Females Males

20 15 10 5

10 0

80

70

60

50

40

30

20

0

0

One Year Period Prevalence (%)

Population prevalence

Age (Years) 18

Migraine without Aura Diagnostic criteria

• 1.1 Migraine without aura – At least 5 attacks (4-72 hours) – Pain features (at least 2) • Unilateral • Pulsating • Moderate to severe intensity • Aggravated by activity – Associated features (at least 1) • Nausea and/or vomiting • Photo and phonophobia – No organic disease ICHD-3 beta Cephalalgia 2013;33:609-828

19

Migraine with Aura Diagnostic criteria

• 1.2 Migraine with Aura – At least 2 attacks – Aura consisting of at least one of the following • Fully reversible visual symptoms • Fully reversible sensory symptoms • Fully reversible dysphasic symptoms – At least 2 of the following • Hemifield or hemisensory symptoms • Development over 5 minutes • Each symptom last >5 and

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