EXPERT ANALYSIS AT THE PREGNANCY MEETING

SAN DIEGO – If a pregnant woman presents with a headache accompanied by nausea, think migraine unless proven otherwise.

“One in five women will have migraines, so the first thing you want to do is get a good history,” Dr. Kathleen B. Digre said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

Dr. Digre, chief of the division of headache and neuro-ophthalmology at the University of Utah, subscribes to the “five histories” of headache, starting with family history. “You want to know if this person is genetically susceptible to migraine, so you want to ask, ‘Does anybody in your family get migraine?’ If they say ‘no, but my mom had sinus headaches,’ that’s telling because most sinus headaches end up being migraine.”

The second phase involves asking about life history of headache, such as having car sickness or abdominal pains as a child.

The third phase involves asking about the history of headache attacks, such as location, frequency, length, and accompanying features, including photophobia, phonophobia, nausea, vomiting, and autonomic symptoms. “I spend some time trying to determine if they have headache with aura, which is a neurologic event, usually visual like zig-zagging lines. But it can affect speech and [result in] numbness in the hand,” Dr. Digre said. “Usually this happens before the headache starts. Then I ask about key features of migraine [such as] are you light sensitive? Sound sensitive? Do you have any nausea? As soon as a person has nausea with a headache and they don’t have a secondary headache, it’s migraine.”

The fourth phase of history-taking involves questions about medical and psychiatric history, “because there are some medical conditions that increase the incidence of headache, such as thyroid disease, anemia, anxiety, and depression,” she said.

The fifth phase involves an investigation of medication history: prescriptions, over-the-counter herbal supplements, and the use of alcohol, amphetamines, or other drugs.

Key components of the physical exam involve taking blood pressure to make sure patients are not preeclamptic, and inspecting the back of their eyes with an ophthalmoscope to rule out papilledema. The brief neurologic exam should also be normal.

Red flags in the history-taking of headache include comments such as “I’ve never had a headache before; I just had a sudden onset of the worst headache of my life.”

“You’ve got to work that one up,” Dr. Digre advised. “That could be an aneurysm or something else serious like reversible cerebral vasoconstriction syndrome.”

Other worrisome signs include unexplained worsening of the headache; changes in the typical headache; headaches that wake people up in the middle of the night; headaches that get worse with coughing, sneezing, or Valsalva maneuver; and headaches that occur in women with underlying cancer, HIV, or some kind of systemic condition or fever. “If I’m worried about a stroke or a TIA I can order an MR with diffusion, which is very sensitive to acute ischemic events,” Dr. Digre said. “A CT scan with contrast is helpful but involves ionizing radiation; I’d rather go with the MR.”

Pregnancy itself impacts women with a preexisting history of migraine. “Often it will worsen the first trimester and migraines will get better the second and third trimester, but there are people who experience worsening of symptoms throughout pregnancy,” she said. “Sometimes migraines start with the pregnancy.”

Dr. Digre noted that women with migraines tend to have a higher incidence of preterm birth and preeclampsia, increased blood pressure, and increased odds of stroke. “Having migraine, especially migraine with aura, should alert you to follow that person closely,” she said.

Dr. Digre emphasized the importance of behavioral approaches to headache and migraine prevention, such as getting ample sleep, eating regularly, and avoiding fasts. “Those are trigger factors for getting migraine,” she said. “You also need to stay hydrated and you need to exercise. People can also do biofeedback and relaxation training.”

As for medications to consider in pregnant patients with migraines, triptans are effective, but Dr. Digre cautions against the use of narcotics, which “set up more headaches and make them harder to treat.”

Antinauseants can be effective, as can tricyclic antidepressants, “especially if people aren’t sleeping well,” she said. “Small doses work. If auras continue I use baby aspirin as a preventive. It usually works well.”

Dr. Digre reported having no relevant financial conflicts.

dbrunk@frontlinemedcom.com On Twitter @dougbrunk

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