Managing Headache in Pregnancy: Q&A With Matthew Robbins, MD

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Migraine with aura is very over-represented in pregnant women – nearly a two-thirds ratio, which is much higher than you see in the general population.
Migraine with aura is very over-represented in pregnant women – nearly a two-thirds ratio, which is much higher than you see in the general population.

Headache during pregnancy is a common complaint resulting from a range of physiologic causes and from the simple added stressors of pending parenthood. Primary headaches such as migraine often improve as a result of stabilizing hormones; however, a history of migraine presents a risk for vascular complications during pregnancy.1 Secondary headaches appearing for the first time often signal potentially serious or life-threatening underlying comorbid conditions, including stroke, cerebral venous thrombosis, subarachnoid hemorrhage, pituitary tumor, choriocarcinoma, eclampsia, preeclampsia, idiopathic intracranial hypertension, and reversible cerebral vasoconstriction syndrome.1

Additionally, a number of medications that are used outside of pregnancy are contraindicated during pregnancy because of safety concerns for the fetus, limiting the pharmacologic options for treatment. Clinicians need to monitor all pregnant women carefully for any new onset of headache or changes in existing headache patterns and provide safe alternative strategies for headache management.

Neurology Advisor spoke with Matthew S. Robbins, MD, FAAN, FAHS, associate professor of neurology at Albert Einstein College of Medicine and director of inpatient services at Montefiore Headache Center in Bronx, New York, to discuss approaches to headache management in this population.

Neurology Advisor: Headache during pregnancy can present a significant problem, especially concerning treatment limitations. How do you prepare patients for what to expect?

Dr Robbins: First, I congratulate them for thinking about their pregnancy in advance and considering what they are going to do about their migraine, because such a high proportion of pregnancies are unintended and often people don't think about migraine and how it may affect treatments that they are taking. There is a lot of counseling in terms of medications they're currently on and what they can continue to use while they're trying to conceive, or once they become pregnant. There are discussions about medications as contingency plans if they experience a bad migraine attack. Then there are a lot of commonsense recommendations how to minimize the chances of triggering migraine during pregnancy. Finally, I educate them about the prognosis of migraine in pregnancy, because the good news is, in most women, migraine gets a lot better when they're pregnant.

NA: How do migraine patterns change during pregnancy?

Dr Robbins: Migraine in general in women is very interrelated to what is happening with estrogen, as it is typically triggered when estrogen levels decline. This happens during the later stages of the menstrual cycle either before or during a period, or on the placebo week of a birth control cycle where there is low or no estrogen content. In pregnancy, estrogen levels steadily increase throughout, and because so many women are responsive to changes in estrogen, that stability and increased level really help make migraine better in pregnancy. In fact, the majority of women with migraine without aura can see migraine improvement or it can go away altogether during pregnancy.

However, there are 2 caveats. In migraine with aura, the prognosis is less certain, because aura can be triggered by higher underlying levels of estrogen, and migraine frequency could theoretically increase, or sometimes migraine with aura first starts when a woman is pregnant. Second, in chronic migraine, which is measured as attacks occurring for at least half of all days for at least 3 months, outcomes during pregnancy have not been well studied, and we are less able to predict the prognosis. One predictive factor for improvement of migraine in pregnancy is whether a woman has a history of menstrual migraine.

Notably, my colleagues and I found that migraine with aura is very overrepresented in pregnant women — nearly a two-thirds ratio, which is much higher than you see in the general population.2 This is important because migraine with aura is more likely to worsen during pregnancy or to be diagnosed for the first time, while migraine without aura usually improves in most women.

NA: What are some of the other headache presentations seen during pregnancy?

Dr Robbins: The most common primary headache diagnosis that we found in our study was migraine, and the most common cause of secondary headache in the later stages of pregnancy was preeclampsia.2 Additionally, pregnancy presents a risk for other secondary headache disorders because of hormonal changes, such as an increase in hypercoagulability and changes in pituitary gland function, leading to diagnoses that are less represented outside of pregnancy, including cerebral venous thrombosis and pituitary disease.

NA: Are there specific types of headache that pose serious risks during pregnancy?

Dr Robbins: Adverse birth outcomes are often associated with headache, and secondary headaches carry risks of their own.3 Migraine is a known risk factor for the development of preeclampsia.4-6 What's not known is, if migraine is well controlled, does the risk for preeclampsia go down. However, a recent study published in the New England Journal of Medicine7 found a reduction in the incidence of preeclampsia in at-risk women who were given baby aspirin. A history of migraine has also been looked at for a number of other pregnancy complications such as elevated risk for preterm labor and a slightly increased risk for low birth weight, but neither have been consistently shown across studies.

NA: How does pregnancy affect treatment plans for migraine?

Dr Robbins: In almost all circumstances, unless someone has really severe migraine, we generally wean patients off any preventive medication before a woman tries to conceive. The prognosis for improvement of migraines during pregnancy contributes to this decision, and of course, we want pregnant women to be on as few medications as possible to prevent any adverse effects to the developing fetus.

NA: Do you have advice regarding nonpharmacologic methods to avoid or treat headaches during pregnancy?

Dr Robbins: I think some of the commonsense strategies of avoiding triggers is critical. Pregnancy is a time when usual routines can be disrupted, so the normal lifestyle strategies to help migraine should be especially emphasized during pregnancy. These include staying well hydrated (especially in early parts of pregnancy if someone has morning sickness), and getting regular sleep and maintaining low-grade or normal-level exercise. Nonpharmacologic treatments that are strongly evidence based for migraine, including biofeedback and relaxation training, certainly are good treatment strategies as well as preventive measures.

Overall, screening for a history headache should be a routine part of a prenatal visit. The worst time to figure out what to do is when someone presents in a crisis, where they have had an attack at home or they are having symptoms and feeling helpless. This does not have to be the case, as there are many treatments available that could be safe in pregnancy.

References

  1. Negro A, Delaruelle Z, Ivanova TA, et al. Headache and pregnancy: a systematic review. J Headache Pain. 2017;18:106.
  2. Robbins MS, Farmakidis C, Dayal AK, Lipton RB. Acute headache diagnosis in pregnant women: a hospital-based study. Neurology. 2015;85:1024-1030.
  3. Grossman TB, Robbins MS, Govindappagari S, Dayal AK. Delivery outcomes of patients with acute migraine in pregnancy: a retrospective study. Headache. 2017;57:605-611.
  4. Facchinetti F, Allais G, Nappi RE, et al. Migraine is a risk factor for hypertensive disorders in pregnancy: a prospective cohort study. Cephalalgia. 2009;29:286-292.
  5. Sanchez SE, Qiu C, Williams MA, Lam N, Sorensen TK. Headaches and migraines are associated with an increased risk of preeclampsia in Peruvian women. Am J Hypertens. 2008;21:360-364.
  6. Adeney KL, Williams MA, Miller RS, Frederick IO, Sorensen TK, Luthy DA. Risk of preeclampsia in relation to maternal history of migraine headaches. J Matern Fetal Neonatal Med. 2005;18:167-172.
  7. Rolnik DL, Wright D, Poon LC, et al. Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. N Engl J Med. 2017;377:613-622. 

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