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Secondary Headaches During Pregnancy: When to Worry

  • Headache (R.B. Halker Singh, Section Editor)
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Abstract

Purpose of Review

Headaches in pregnancy are a frequent cause of worry for both patients and healthcare providers. Physiological changes during this period increase the risk of a number of secondary headache disorders, and often also have an impact on primary headache disorders. This article reviews recent research into distinguishing worrisome vs non-worrisome headache presentations during pregnancy.

Recent Findings

Recent research suggests that secondary causes of headache are highly prevalent during pregnancy, in between 25 and 42.4% of women seeking medical attention. Secondary causes of headache in pregnancy are most commonly homeostatic disturbances and hypertensive disorders of pregnancy, vascular problems, space-occupying lesions, and infections. Migraine itself also increases the risk of hypertensive disorders of pregnancy. Specific red flags for a secondary cause of headache in pregnancy include absence of any headache history, more severe pain, systemic features such as elevated blood pressure, and abnormal laboratory tests including thrombocytopenia or thrombocytosis, elevated liver function tests, elevated C-reactive protein, or proteinuria, in addition to traditional red flags, such as a change in headache pattern.

Summary

Secondary causes of headache are common in women seeking medical attention during pregnancy. Red flags for secondary causes of headache during pregnancy may be remembered with the mnemonic PREGNANT HA (proteinuria, rapid onset, elevated blood pressure or temperature, gestational age in third trimester, neurological signs or symptoms, altered level of consciousness, no headache history or known history of a secondary headache disorder, thrombocytopenia or thrombocytosis, high liver function tests or CRP, or agonizingly severe pain). Increased education of patients and their providers may help improve selection of patients for workup of a secondary cause.

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References

Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. Dodick DW. Clinical clues and clinical rules: primary vs secondary headache. Adv Stud Med. 2003;3(6C):S550–5.

    Google Scholar 

  2. Do TP, Remmers A, Schytz H, Schankin C, Nelson S, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019;92(3):134–44. https://doi.org/10.1212/WNL.0000000000006697.

    Article  PubMed  Google Scholar 

  3. Goadsby PJ, Goldberg J, Silberstein SD. Migraine in pregnancy. BMJ. 2008;336(7659):1502–4.

    Article  Google Scholar 

  4. Negro A, Delaruelle Z, Ivanova T, Khan S, Ornello R, et al. Headache and pregnancy: a systematic review. J Headache Pain. 2017;18(1):106. https://doi.org/10.1186/s10194-017-0816-0.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Afridi S. Current concepts in migraine and their relevance to pregnancy. Obstet Med. 2018;11(4):154–9.

    Article  Google Scholar 

  6. •• Robbins MS, Farmakidis C, Dayal AK, Lipton B. Acute headache diagnosis in pregnant women. Neurology. 2015;85(12):1024–30. https://doi.org/10.1212/WNL.0000000000001954. The authors identified a secondary headache disorder in 35% of included patients, and provide an overview of associated causes and factors associated with a secondary headache diagnosis.

    Article  PubMed  PubMed Central  Google Scholar 

  7. •• Raffaelli B, Siebert E, Körner J, Liman T, Reuter U, et al. Characteristics and diagnoses of acute headache in pregnant women - a retrospective cross-sectional study. J Headache Pain. 2017;18(1):114. https://doi.org/10.1186/s10194-017-0823-1. The authors identified a secondary headache diagnosis prevalence of 42.4% in the included patients, and they identified clinical and paraclinical features associated with a secondary headache diagnosis.

    Article  PubMed  PubMed Central  Google Scholar 

  8. •• Raffaelli B, Neeb L, Israel-Willner H, Körner J, Liman T, et al. Brain imaging in pregnant women with acute headache. J Neurol. 2018;265(8):1836–43. https://doi.org/10.1007/s00415-018-8924-6. The authors further analyzed the patients from [7] undergoing neuroimaging, and provide further refinement of factors associated with a secondary cause of headache in pregnancy.

    Article  PubMed  Google Scholar 

  9. ACOG Practice Bulletin No. 202: gestational hypertension and preeclampsia. Obstet Gynecol. 2019;133(1):e1–e25. https://doi.org/10.1097/AOG.0000000000003018.

  10. Gudu W. Prodromal symptoms, health care seeking in response to symptoms and associated factors in eclamptic patients. BMC Pregnancy Childbirth. 2017;17(1):87. https://doi.org/10.1186/s12884-017-1272-1.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Wagner SJ, Acquah LA, Lindell EP, Craici IM, Wingo MT, Rose CH, et al. Posterior reversible encephalopathy syndrome and eclampsia: pressing the case for more aggressive blood pressure control. Mayo Clin Proc. 2011;86(9):851–6.

    Article  Google Scholar 

  12. Salles GF, Schlüssel MM, Farias DR, Franco-Sena AB, Rebelo F, et al. Blood pressure in healthy pregnancy and factors associated with no mid-trimester blood pressure drop: a prospective cohort study. Am J Hypertens. 2015;28(5):680–9.

    Article  CAS  Google Scholar 

  13. Kurdoglu Z, Cetin O, Sayın R, Dirik D, Kurdoglu M, Kolusarı A, et al. Clinical and perinatal outcomes in eclamptic women with posterior reversible encephalopathy syndrome. Arch Gynecol Obstet. 2015;292(5):1013–8. https://doi.org/10.1007/s00404-015-3738-6.

    Article  PubMed  Google Scholar 

  14. Ban L, Sprigg N, Abdul Sultan A, Nelson-Piercy C, Bath P, et al. Incidence of first stroke in pregnant and nonpregnant women of childbearing age: a population-based cohort study from England. J Am Heart Assoc. 2017;6(4). https://doi.org/10.1161/JAHA.116.004601.

  15. Demel S, Kittner S, Ley S, McDermott M, Rexrode K. Stroke risk factors unique to women. Stroke. 2018;49:518–23. https://doi.org/10.1161/STROKEAHA.117.018415.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Miller E, Sundheim K, Willey J, Boehme A, Agalliu D, et al. The impact of pregnancy on hemorrhagic stroke in young women. Cerebrovasc Dis. 2018;46(1–2):10–5. https://doi.org/10.1159/000490803.

    Article  PubMed  Google Scholar 

  17. Tanaka K, Matsushima M, Matsuzawa Y, Wachi Y, Izawa T, Sakai K, et al. Antepartum reversible cerebral vasoconstriction syndrome with pre-eclampsia and reversible posterior leukoencephalopathy. J Obstet Gynaecol Res. 2015;41(11):1843–7. https://doi.org/10.1111/jog.12788.

    Article  PubMed  Google Scholar 

  18. Groenestege A, Rinkel G, van der Bom J, Algra A, Klijn C. The risk of aneurysmal subarachnoid hemorrhage during pregnancy, delivery, and the puerperium in the Utrecht population. Stroke. 2009;40(4):1148–51. https://doi.org/10.1161/STROKEAHA.108.539700.

    Article  Google Scholar 

  19. Kim YW, Neal D, Hoh B. Cerebral aneurysms in pregnancy and delivery: pregnancy and delivery do not increase the risk of aneurysm rupture. Neurosurgery. 2013;72(2):143–9; discussion 150. https://doi.org/10.1227/NEU.0b013e3182796af9.

    Article  PubMed  Google Scholar 

  20. Liu X, Wang S, Zhao Y, Teo M, Guo P, Zhang D, et al. Risk of cerebral arteriovenous malformation rupture during pregnancy and puerperium. Neurology. 2014;82(20):1798–803. https://doi.org/10.1212/WNL.0000000000000436.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Kataoka. Subarachnoid hemorrhage from intracranial aneurysms during pregnancy and the puerperium. Neurol Med Chir (Tokyo). 2013;53(8):549–54.

    Article  Google Scholar 

  22. Barbarite E, Hussain S, Dellarole A, Elhammady M, Peterson E. The management of intracranial aneurysms during pregnancy: a systematic review. Turk Neurosurg. 2016;26(4):465–74. https://doi.org/10.5137/1019-5149.JTN.15773-15.0.

    Article  PubMed  Google Scholar 

  23. Porras J, Yang W, Philadelphia E, Law J, Garzon-Muvdi T, et al. Hemorrhage risk of brain arteriovenous malformations during pregnancy and puerperium in a North American cohort. Stroke. 2017;48:1507–13. https://doi.org/10.1161/STROKEAHA.117.016828.

    Article  PubMed  Google Scholar 

  24. Ferro J, Canhão P, Stam J, Bousser M, Barinagarrementeria F, et al. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke. 2004;35(3):664–70.

    Article  Google Scholar 

  25. Kashkoush AI, Ma H, Agarwal N, Panczykowski D, Tonetti D, Weiner GM, et al. Cerebral venous sinus thrombosis in pregnancy and puerperium: a pooled, systematic review. J Clin Neurosci. 2017;39:9–15. https://doi.org/10.1016/j.jocn.2017.02.046.

    Article  PubMed  Google Scholar 

  26. Duman T, Uluduz D, Midi I, Bektas H, Kablan Y, Goksel BK, et al. A multicenter study of 1144 patients with cerebral venous thrombosis: the VENOST study. J Stroke Cerebrovasc Dis. 2017;26(8):1848–57. https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.04.020.

    Article  PubMed  Google Scholar 

  27. Botta R, Donirpathi S, Yadav R, Kulkarni GB, Kumar MV, Nagaraja D. Headache patterns in cerebral venous sinus thrombosis. J Neurosci Rural Pract. 2017;8(Suppl 1):S72–7.

    PubMed  PubMed Central  Google Scholar 

  28. Maderia L, Hoffman M, Shlossman P. Internal carotid artery dissection as a cause of headache in the second trimester. Am J Obstet Gynecol. 2007;196(1):e7–8. https://doi.org/10.1016/j.ajog.2006.09.044.

    Article  PubMed  Google Scholar 

  29. Mohammed I, Aaland M, Khan N, Crossley I. A young pregnant woman with spontaneous carotid artery dissection--unknown mechanisms. BMJ Case Rep. 2014;2014. https://doi.org/10.1136/bcr-2013-202541.

    Google Scholar 

  30. Ulrich N, Johnson A, Jodry D, Dola C, Martin-Schild S, el Khoury R. Resolution of internal carotid dissection with middle cerebral artery occlusion in pregnancy. Case Rep Neurol Med. 2015;2015:398261. https://doi.org/10.1155/2015/398261.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Shanmugalingam R, Reza Pour N, Chuah S, Vo T, Beran R, et al. Vertebral artery dissection in hypertensive disorders of pregnancy: a case series and literature review. BMC Pregnancy Childbirth. 2016;16:164. https://doi.org/10.1186/s12884-016-0953-5.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Elhfnawy AM, Solymosi L, Sommer C. Carotid dissection presenting as a prolonged cluster-like headache in a patient with episodic cluster headache. BMJ Case Rep. 2017;2017:bcr2017220845.

    Article  Google Scholar 

  33. Ennaifer H, Jemel M, Kandar H, Grira W, Kammoun I, Salem LB. Developed diplopia due to a pituitary macroadenoma during pregnancy. Pan Afr Med J. 2018;29:39. https://doi.org/10.11604/pamj.2018.29.39.12706.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Kurdoglu Z, Cetin O, Gulsen I, Dirik D, Bulut M. Intracranial meningioma diagnosed during pregnancy caused maternal death. Case Rep Med. 2014;2014:158326. https://doi.org/10.1155/2014/158326.

    Article  PubMed  PubMed Central  Google Scholar 

  35. van Westrhenen A, Senders J, Martin E, DiRisio A, Broekman M. Clinical challenges of glioma and pregnancy: a systematic review. J Neuro-Oncol. 2018;139(1):1–11. https://doi.org/10.1007/s11060-018-2851-3.

    Article  Google Scholar 

  36. Watson V. An unexpected headache: pituitary apoplexy in a pregnant woman on anticoagulation. BMJ Case Rep. 2015;2015. https://doi.org/10.1136/bcr-2015-210198.

    Google Scholar 

  37. Abraham RR, Pollitzer R, Gokden M, Goulden P. Spontaneous pituitary apoplexy during the second trimester of pregnancy, with sensory loss. BMJ Case Rep. 2016;2016. https://doi.org/10.1136/bcr-2015-212405.

  38. Digre KB, Varner MW, Corbett JJ. Pseudotumor cerebri and pregnancy. Neurology. 1984;34(6):721–9.

    Article  CAS  Google Scholar 

  39. Tang RA, Dorotheo EU, Schiffman JS, Bahrani HM. Medical and surgical management of idiopathic intracranial hypertension in pregnancy. Curr Neurol Neurosci Rep. 2004;4(5):398–409.

    Article  Google Scholar 

  40. Golan S, Maslovitz S, Kupferminc MJ, Kesler A. Management and outcome of consecutive pregnancies complicated by idiopathic intracranial hypertension. Isr Med Assoc J. 2013;15(4):160–3.

    PubMed  Google Scholar 

  41. Kesler A, Kupferminc M. Idiopathic intracranial hypertension and pregnancy. Clin Obstet Gynecol. 2013;56(2):389–96. https://doi.org/10.1097/GRF.0b013e31828f2701.

    Article  PubMed  Google Scholar 

  42. Hashmi M. Low-pressure headache presenting in early pregnancy with dramatic response to glucocorticoids: a case report. J Med Case Rep. 2014;8:115. https://doi.org/10.1186/1752-1947-8-115.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Grange J, Lorre G, Ducarme G. Iterative epidural blood patch for recurrent spontaneous intracranial hypotension during pregnancy. J Clin Anesth. 2016;34:239–43. https://doi.org/10.1016/j.jclinane.2016.04.040.

    Article  PubMed  Google Scholar 

  44. Roine S, Pöyhönen M, Timonen S, Tuisku S, Marttila R, et al. Neurologic symptoms are common during gestation and puerperium in CADASIL. Neurology. 2005;64(8):1441–3.

    Article  CAS  Google Scholar 

  45. Say RE, Whittaker RG, Turnbull HE, McFarland R, Taylor RW, Turnbull DM. Mitochondrial disease in pregnancy: a systematic review. Obstet Med. 2011;4(3):90–4.

    Article  CAS  Google Scholar 

  46. Rozen TD. Neurological picture. A new headache during late pregnancy: consider the nasal mucosa as a ‘point’ of reference. J Neurol Neurosurg Psychiatry. 2014;85(1):112–3. https://doi.org/10.1136/jnnp-2013-305403.

    Article  PubMed  Google Scholar 

  47. Grossman TB, Robbins M, Govindappagari S, Dayal A. Delivery outcomes of patients with acute migraine in pregnancy: a retrospective study. Headache. 2017;57(4):605–11. https://doi.org/10.1111/head.13023.

    Article  PubMed  Google Scholar 

  48. Wabnitz A, Bushnell C. Migraine, cardiovascular disease, and stroke during pregnancy: systematic review of the literature. Cephalalgia. 2015;35:132–9. https://doi.org/10.1177/0333102414554113.

    Article  PubMed  Google Scholar 

  49. Facchinetti F, Sacco A. Preeclampsia and migraine: a prediction perspective. Neurol Sci. 2018;39(Suppl 1):79–80. https://doi.org/10.1007/s10072-018-3352-z.

    Article  PubMed  Google Scholar 

  50. Ailani J. Migraine and patent foramen ovale. Curr Neurol Neurosci Rep. 2014;14(2):426. https://doi.org/10.1007/s11910-013-0426-4.

    Article  PubMed  Google Scholar 

  51. Takagi H. A meta-analysis of case-control studies of the association of migraine and patent foramen ovale. J Cardiol. 2016;67(6):493–503. https://doi.org/10.1016/j.jjcc.2015.09.016.

    Article  PubMed  Google Scholar 

  52. Chen L, Deng W, Palacios I, Inglessis-Azuaje I, McMullin D, Zhou D, et al. Patent foramen ovale (PFO), stroke and pregnancy. J Investig Med. 2016;64(5):992–1000. https://doi.org/10.1136/jim-2016-000103.

    Article  PubMed  PubMed Central  Google Scholar 

  53. •• Vgontzas A, Robbins M. A hospital based retrospective study of acute postpartum headache. Headache. 2018;58(6):845–51. https://doi.org/10.1111/head.13279. This recent study on post-partum headache specifically identified a very high prevalence of secondary causes for post-partum headache, in 73% of included patients.

    Article  PubMed  Google Scholar 

  54. Reddi S, Honchar V, Robbins M. Pneumocephalus associated with epidural and spinal anesthesia for labor. Neurol Clin Pract. 2015;5(5):376–82. https://doi.org/10.1212/CPJ.0000000000000178.

    Article  PubMed  PubMed Central  Google Scholar 

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  1. Women’s College Hospital Centre for Headache, Division of Neurology, University of Toronto, 76 Grenville St., Toronto, Ontario, M5S 1B2, Canada

    Claire H. Sandoe & Christine Lay

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Claire H. Sandoe and Christine Lay each declare no potential conflicts of interest.

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Sandoe, C.H., Lay, C. Secondary Headaches During Pregnancy: When to Worry. Curr Neurol Neurosci Rep 19, 27 (2019). https://doi.org/10.1007/s11910-019-0944-9

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