Advertisement

Treatment of Pregnant and Breastfeeding Patients with Acute Headache in the ED

Chapter
  • 574 Downloads

Key Chapter Points

Most headaches occurring during pregnancy and breastfeeding are benign, ­primary headaches. Secondary headaches should be ruled out in pregnant and nursing women using necessary testing, including spinal fluid examination and neuroimaging, when appropriate. The anti-emetic of choice for pregnant and lactating women is ondansetron. Pain medication treatments of choice for pregnant women include intravenous therapy with ketorolac (second trimester only), magnesium, or hydromorphone. Intranasal lidocaine drops are safe and sometimes helpful for migraine. Pain medication treatments of choice for lactating women include subcutaneous sumatriptan or intravenous therapy with ketorolac, valproate (provided that reliable contraception can be ensured), magnesium, or hydromorphone. Ketorolac may also be given intramuscularly. Prochlorperazine can be used to help relieve both nausea and other migraine symptoms during lactation. Patients with residual headache after standard treatments may benefit from trigger point injections, a greater occipital nerve block, or a short course of prednisone.

Keywords

Breastfeeding Conception Dehydration Lactation Nursing Pregnancy 

References

  1. 1.
    Kelly RH, Russo J, Katon W. Somatic complaints among pregnant women cared for in obstetrics: normal pregnancy or depressive and anxiety symptom amplification revisited? Gen Hosp Psychiatry. 2011;23:107–13.CrossRefGoogle Scholar
  2. 2.
    Melhado EM, Maciel JA, Guerreiro CM. Headache during gestation: evaluation of 1101 women. Can J Neurol Sci. 2007;34:187–92.PubMedGoogle Scholar
  3. 3.
    Goldszmidt E, Chettle C, Kern R, et al. The incidence and etiology of postpartum headaches. Can J Anesth. 2004;51:A59.CrossRefGoogle Scholar
  4. 4.
    Douglas KA, Redman CW. Eclampsia in the United Kingdom. BMJ. 1994;309:1395–400.PubMedGoogle Scholar
  5. 5.
    Callaghan N. The migraine syndrome in pregnancy. Neurology. 1968;18:197–9.PubMedGoogle Scholar
  6. 6.
    Granella F, Sances G, Zanferrari C, et al. Migraine without aura and reproductive life events: a clinical epidemiological study in 1300 women. Headache. 1993;33:385–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Chen TC, Leviton A. Headache recurrences in pregnant women with migraine. Headache. 1994;34:107–10.PubMedCrossRefGoogle Scholar
  8. 8.
    Maggiono F, Alessi C, Maggino T, et al. Primary headaches and pregnancy. Cephalalgia. 1995;15:54.Google Scholar
  9. 9.
    Marcus DA, Scharff L, Turk DC. Longitudinal prospective study of headache during pregnancy and postpartum. Headache. 1999;39:625–32.PubMedCrossRefGoogle Scholar
  10. 10.
    Sances G, Granella F, Nappi RE, et al. Course of migraine during pregnancy and postpartum: a prospective study. Cephalalgia. 2003;23:197–205.PubMedCrossRefGoogle Scholar
  11. 11.
    Manzoni GC, Micieli G, Granella F, et al. Cluster headache in women: clinical findings and relationship with reproductive life. Cephalalgia. 1988;8:37–44.PubMedCrossRefGoogle Scholar
  12. 12.
    van Vliet JA, Favier I, Helmerhorst FM, Haan J, Ferrari MD. Cluster headache in women: relation with menstruation, use of oral contraceptives, pregnancy, and menopause. J Neurol Neurosurg Psychiatry. 2006;77:690–2.PubMedCrossRefGoogle Scholar
  13. 13.
    Davis LE. Normal laboratory values of CSF during pregnancy. Arch Neurol. 1979;36:443.PubMedGoogle Scholar
  14. 14.
    Kanal E, Barkovich AJ, Bell C, et al. ACR guidance document for safe MR practices: 2007. AJR Am J Roentgenol. 2007;188:1447–74.PubMedCrossRefGoogle Scholar
  15. 15.
    Levine D, Barnes PD, Edleman RR. Obstetric MR imaging. Radiology. 1999;211:609–17.PubMedGoogle Scholar
  16. 16.
    Baker P, Johnson I, Harvey P, Mansfield P. A three-year follow-up of children imaged in utero using echo-planar magnetic resonance. Am J Obstet Gynecol. 1994;170:32–3.PubMedGoogle Scholar
  17. 17.
    Kanal E, Gillen J, Evans J, Savitz D, Shellock F. Survey of reproductive health among female MR workers. Radiology. 1993;187:395–9.PubMedGoogle Scholar
  18. 18.
    Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa JK. Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations. Radiography. 2007;27:1705–22.CrossRefGoogle Scholar
  19. 19.
    American College of Obstetricians and Gynaecologists Committee Opinion. Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol. 2004;104:647–51.CrossRefGoogle Scholar
  20. 20.
    Lowe SA. Diagnostic radiography in pregnancy: risks and reality. Aust N Z J Obstet Gynaecol. 2004;44:191–6.PubMedCrossRefGoogle Scholar
  21. 21.
    McCollough CH, Schueler BA, Atwell TD, et al. Radiation exposure and pregnancy: when should we be concerned? Radiographics. 2007;27:909–18.PubMedCrossRefGoogle Scholar
  22. 22.
    Dineen R, Banks A, Lenthall R. Imaging of acute neurological conditions in pregnancy and the puerperium. Clin Radiol. 2005;60:1156–70.PubMedCrossRefGoogle Scholar
  23. 23.
    Webb JW, Thomsen HS, Morcos SK. The use of iodinated and gadolinium contrast media ­during pregnancy and lactation. Eur Radiol. 2005;15:1234–40.PubMedCrossRefGoogle Scholar
  24. 24.
    Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa JK. Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations. Radiographics. 2007;27:1705–22.PubMedCrossRefGoogle Scholar
  25. 25.
    Ramachandren S, Cross BJ, Liebeskind DS. Emergent headaches during pregnancy: correlation between neurologic examination and neuroimaging. Am J Neuroradiol. 2007;28:1085–7.CrossRefGoogle Scholar
  26. 26.
    Addis A, Sharabi S, Bonati M. Risk classification systems for drug use during pregnancy. Are they a reliable source of information? Drug Saf. 2000;23:245–53.PubMedCrossRefGoogle Scholar
  27. 27.
    Schreyer P, Sherman DJ, Ervin MG, Day L, Ross MG. Maternal dehydration: impact on ovine amniotic fluid volume and composition. J Dev Physiol. 1990;13:283–7.PubMedGoogle Scholar
  28. 28.
    Urbanski PK. How does hydration affect preterm labor? AWHONN Lifelines. 1997;1:25.PubMedCrossRefGoogle Scholar
  29. 29.
    Skidmore FM, Williams LS, Fradkin KD, Alonso RJ, Biller J. Presentation, etiology, and ­outcome of stroke in pregnancy and puerperium. J Stroke Cerebrovasc Dis. 2001;10:1–10.PubMedCrossRefGoogle Scholar
  30. 30.
    Agnew CL, Ross MG, Fujino Y, et al. Maternal/fetal dehydration: prolonged effects and responses to oral hydration. Am J Physiol. 1993;264:R197–203.PubMedGoogle Scholar
  31. 31.
    Power ML, Milligan LA, Schulkin J. Managing nausea and vomiting of pregnancy: a survey of obstetrician-gynecologists. J Reprod Med. 2007;52:922–8.PubMedGoogle Scholar
  32. 32.
    Evers S, Áfra J, Frese A, et al. EFNS guideline on the drug treatment of migraine – report of an EFNS task force. Eur J Neurol. 2006;13:560–72.PubMedCrossRefGoogle Scholar
  33. 33.
    Koren G, Florescu A, Costei AM, Boskovic R, Moretti ME. Nonsteroidal antiinflammatory drugs during third trimester and the risk of premature closure of the ductus arteriosus: a meta-analysis. Ann Pharmacother. 2006;40:824–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Bigal ME, Bordini CA, Tepper SJ, Speciali JG. Intravenous magnesium sulphate in the acute treatment of migraine without aura and migraine with aura. A randomized, double-blind, placebo-controlled study. Cephalalgia. 2002;22:345–53.PubMedCrossRefGoogle Scholar
  35. 35.
    Cete Y, Dora B, Ertan C, Ozdemir C, Oktay C. A randomized prospective placebo-controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the Emergency Department. Cephalalgia. 2005;25:199–204.PubMedCrossRefGoogle Scholar
  36. 36.
    Maizels M, Scott B, Cohen W, Chen W. Intranasal lidocaine for treatment of migraine: a ­randomized, double-blind, controlled trial. JAMA. 1996;276:319–21.PubMedCrossRefGoogle Scholar
  37. 37.
    Maizels M, Geiger AM. Intranasal lidocaine for migraine: a randomized trial and open-label follow-up. Headache. 1999;39:543–51.PubMedCrossRefGoogle Scholar
  38. 38.
    Blanda M, Rench T, Gerson LW, Weigand JV. Intranasal lidocaine for the treatment of migraine headache: a randomized, controlled trial. Acad Emerg Med. 2001;8:337–42.PubMedCrossRefGoogle Scholar
  39. 39.
    Tornabene SV, Deutsch R, Davis DP, Chan TC, Vilke GM. Evaluating the use and timing of opioids for the treatment of migraine headaches in the emergency department. J Emerg Med. 2009;36:333–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Von Seggern RL, Adelman JU. Practice and economics cost considerations in headache ­treatment. Part 2: acute migraine treatment. Headache. 1996;36:493–502.CrossRefGoogle Scholar
  41. 41.
    Borhani Haghighi A, Motazedian S, Rezaii R, et al. Cutaneous application of menthol 10% solution as an abortive treatment of migraine without aura: a randomised, double-blind, ­placebo-controlled, crossed-over study. Int J Clin Pract. 2010;64:451–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Mahadevan U, Kane S. American gastroenterological association institute medical position statement on the use of gastrointestinal medications in pregnancy. Gastroenterology. 2006;131:283–311.PubMedCrossRefGoogle Scholar
  43. 43.
    Beaulac-Baillargeon L, Allard G. Distribution of indomethacin in human milk and estimation of its mil to plasma ratio in vitro. Br J Clin Pharmacol. 1993;36:413–6.PubMedGoogle Scholar
  44. 44.
    Gardiner SJ, Doogue MP, Zhang M, Begg EJ. Quantification of infant exposure to celecoxib through breast milk. Br J Clin Pharmacol. 2006;61:101–4.PubMedCrossRefGoogle Scholar
  45. 45.
    Ilett KF, Paech MJ, Page-Sharp M, et al. Use of a sparse sampling study design to assess transfer of tramadol and its O-desmethyl metabolite into transitional breast milk. Br J Clin Pharmacol. 2008;65:661–6.PubMedCrossRefGoogle Scholar
  46. 46.
    Wojnar-Horton RE, Hackett LP, et al. Distribution and excretion of sumatriptan in human milk. Br J Clin Pharmacol. 1996;41:217–21.PubMedCrossRefGoogle Scholar
  47. 47.
    Waberzinek G, Marková J, Mastík J. Safety and efficacy of intravenous sodium valproate in the treatment of acute migraine. Neuro Endocrinol Lett. 2007;28:59–64.PubMedGoogle Scholar
  48. 48.
    Kligler B, Chaudhary S. Peppermint oil. Am Fam Phys. 2007;75:1027–30.Google Scholar
  49. 49.
    Jürgens TP, Schaefer C, May A. Treatment of cluster headache in pregnancy and lactation. Cephalalgia. 2009;29:391–400.PubMedCrossRefGoogle Scholar
  50. 50.
    Giraud P, Chauvet S. Cluster headache during pregnancy: case report and literature review. Headache. 2009;49:136–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Simbar M, Karimian Z, Afrakhteh M, Akbarzadeh A, Kouchaki E. Increased risk of pre-eclampsia (PE) among women with the history of migraine. Clin Exp Hypertens. 2010;32:159–65.PubMedCrossRefGoogle Scholar
  52. 52.
    Panagariya A, Maru A. Cerebral venous thrombosis in pregnancy and puerperium – a prospective study. J Assoc Physicians India. 1997;45:857–9.PubMedGoogle Scholar
  53. 53.
    Azpilcueta A, Peral C, Giraldo I, Chen FJ, Contreras G. Meningioma in pregnancy. Report of a case and review of the literature. Ginecol Obstet Mex. 1995;63:349–51.Google Scholar
  54. 54.
    Saitoh Y, Oku Y, Izumoto S, Go J. Rapid growth of a meningioma during pregnancy: relationship with estrogen and progesterone receptors – case report. Neurol Med Chir (Tokyo). 1989;29:440–3.CrossRefGoogle Scholar
  55. 55.
    Arseni C, Simoca I, Jipescu I, Leventi E, Grecu P, Sima A. Pseudotumor cerebri: risk factors, clinical course, prognostic criteria. Rom J Neurol Psychiatry. 1992;30:115–32.PubMedGoogle Scholar
  56. 56.
    Katz VL, Peterson R, Cefalo RC. Pseudotumor cerebri and pregnancy. Am J Perinatol. 1989;6:442–5.PubMedCrossRefGoogle Scholar
  57. 57.
    Koontz WL, Herbert WP, Cefalo RC. Pseudotumor cerebri in pregnancy. Obstet Gynecol. 1983;62:324–7.PubMedCrossRefGoogle Scholar
  58. 58.
    Evans RW, Lee AG. Idiopathic intracranial hypertension in pregnancy. Headache. 2010;50:1513–5.PubMedCrossRefGoogle Scholar
  59. 59.
    Koren G, Clark S, Hankins GD, et al. Effectiveness of delayed-release doxylamine and pyridoxine for nausea and vomiting of pregnancy: a randomized placebo controlled trial. Am J Obstet Gynecol. 2010;203:571.e1–7.CrossRefGoogle Scholar
  60. 60.
    Coutinho JM, Ferro JM, Canhão P, et al. Cerebral venous and sinus thrombosis in women. Stroke. 2009;40:2356–61.PubMedCrossRefGoogle Scholar
  61. 61.
    Rodriguez-Thompson D, Lieberman ES. Use of a random urinary protein-to-creatinine ratio for the diagnosis of significant proteinuria during pregnancy. Am J Obstet Gynecol. 2001;185:808–11.PubMedCrossRefGoogle Scholar
  62. 62.
    Griffith JD, Mycyk MB, Kyriacou DN. Metoclopramide versus hydromorphone for the ­emergency department treatment of migraine headache. J Pain. 2008;9:88–94.PubMedCrossRefGoogle Scholar
  63. 63.
    Friedman BW, Corbo J, Lipton RB, et al. A trial of metoclopramide vs sumatriptan for the emergency department treatment of migraines. Neurology. 2005;64:463–8.PubMedCrossRefGoogle Scholar
  64. 64.
    Miner JR, Fish SJ, Smith SW, Biros MH. Droperidol vs. prochlorperazine for benign headaches in the emergency department. Acad Emerg Med. 2001;8:873–9.PubMedCrossRefGoogle Scholar
  65. 65.
    Richman PB, Allegra J, Eskin B, et al. A randomized clinical trial to assess the efficacy of intramuscular droperidol for the treatment of acute migraine headache. Am J Emerg Med. 2002;20:39–42.PubMedCrossRefGoogle Scholar
  66. 66.
    Friedman BW, Esses D, Solorzano C, et al. Evaluating the use and timing of opioids for the treatment of migraine headaches in the emergency department. Ann Emerg Med. 2008;52:399–406.PubMedCrossRefGoogle Scholar
  67. 67.
    Engindeniz Z, Demircan C, Karli N, et al. Intramuscular tramadol vs. diclofenac sodium for the treatment of acute migraine attacks in emergency department: a prospective, randomised, double-blind study. J Headache Pain. 2005;6:143–8.PubMedCrossRefGoogle Scholar
  68. 68.
    American Academy of Pediatric Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics. 2001;108:776–89.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Department of AnesthesiologyUniversity of PittsburghPittsburghUSA
  2. 2.Dean Health SystemsMadisonUSA

Personalised recommendations