Acute headache diagnosis in pregnant women

Abstract

Objective: To characterize demographic and clinical features in pregnant women presenting with acute headache, and to identify clinical features associated with secondary headache. Methods:We conducted a 5-year, single-center, retrospective study of consecutive pregnant women presenting to acute care with headache receiving neurologic consultation.Results: The 140 women had a mean age of 29 6 6.4 years and often presented in the third trimester (56.4%). Diagnoses were divided into primary (65.0%) and secondary (35.0%) disorders. The most common primary headache disorder was migraine (91.2%) and secondary headache disorders were hypertensive disorders (51.0%). The groups were similar in demographics, gestational ages, and most headache features. In univariate analysis, secondary headaches were associated with a lack of headache history (36.7% vs 13.2%, p 5 0.0012), seizures (12.2% vs 0.0%, p 5 0.0015), elevated blood pressure (55.1% vs 8.8%, p , 0.0001), fever (8.2% vs 0.0%, p 5 0.014), and an abnormal neurologic examination (34.7% vs 16.5%, p 5 0.014). In multivariate logistic regression, elevated blood pressure (odds ratio [OR] 17.0, 95% confidence interval [CI] 4.2-56.0) and a lack of headache history (OR 4.9, 95% CI 1.7-14.5) had an increased association with secondary headache, while psychiatric comorbidity (OR 0.13, 95% CI 0.021-0.78) and phonophobia (OR 0.29, 95% CI 0.09-0.91) had a reduced association with secondary headache.Conclusions: Among pregnant women receiving inpatient neurologic consultation, more than onethird have secondary headache. Diagnostic vigilance should be heightened in the absence of a headache history and if seizures, hypertension, or fever are present. Attack features may not adequately distinguish primary vs secondary disorders, and low thresholds for neuroimaging and monitoring for preeclampsia are justified. Neurology ® 2015;85:1024-1030 GLOSSARY CI 5 confidence interval; HELLP 5 hemolysis, elevated liver enzymes, and low platelet count; ICHD-3 beta 5 International Classification of Headache Disorders, 3rd edition (beta version); OR 5 odds ratio; PRES 5 posterior reversible encephalopathy syndrome.The most common primary headache disorders have a peak prevalence and incidence at a younger age and affect women disproportionately, particularly during childbearing years.1 The female predilection may be explained by the relationship of headache and sex hormones, particularly estrogen.2 Migraine is the most common disabling primary headache disorder, and, in pregnancy, retrospective and prospective studies consistently demonstrate that by the second trimester, migraine frequency typically improves, although attacks of migraine with aura and aura without headache may not reflect this pattern. [3][4][5][6][7][8][9][10] Acute, severe headache in pregnancy is generally regarded as a "red flag" and a cause for further investigation, particularly when new onset. [11][12][13] Various secondary headache disorders are more likely to occur during this time period, 12 possibly related t...

A Hospital Based Retrospective Study of Acute Postpartum Headache

“…9 PDPH was the most common secondary headache disorder diagnosed; however, headaches attributable to postpartum PEC or cerebrovascular disorders comprised half of secondary headaches. In contrast, secondary headache comprised only 35% of diagnoses in contemporaneous acute headache consultations during pregnancy at our institution.…”

“…In contrast, secondary headache comprised only 35% of diagnoses in contemporaneous acute headache consultations during pregnancy at our institution. 9 PDPH was the most common secondary headache disorder diagnosed; however, headaches attributable to postpartum PEC or cerebrovascular disorders comprised half of secondary headaches. The high rate of secondary headaches in our study should be appreciated within a sample for which urgent neurology consultation was requested.…”

ACR Appropriateness Criteria® Headache

“…Pregnant patients with new, progressive, or changes in chronic headache patterns have higher yields of abnormalities on imaging [70], although much of the literature on headache in pregnancy is centered on examination rather than imaging findings [71][72][73][74]. Please see the Safety Considerations in Pregnant Patients section later for details.…”

Migraine Treatment in Pregnant Women Presenting to Acute Care: A Retrospective Observational Study

“…Migraine is a common problem among pregnant women, with prevalence in pregnancy reported as high as 35% . While migraine typically improves during pregnancy, many women have a stable or worsening course and may even experience first‐time migraine attacks . Twenty‐six percent of women with migraine during the first trimester of pregnancy report moderate or severe headache‐related disability …”