Skip to main content
SpringerLink
Log in

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

  • Chapter
  • First Online:
Practical Assessment and Treatment of the Patient with Headaches in the Emergency Department and Urgent Care Clinic

  • 656 Accesses

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.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 39.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 54.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  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.

    Article  Google Scholar 

  2. Melhado EM, Maciel JA, Guerreiro CM. Headache during gestation: evaluation of 1101 women. Can J Neurol Sci. 2007;34:187–92.

    PubMed  Google Scholar 

  3. Goldszmidt E, Chettle C, Kern R, et al. The incidence and etiology of postpartum headaches. Can J Anesth. 2004;51:A59.

    Article  Google Scholar 

  4. Douglas KA, Redman CW. Eclampsia in the United Kingdom. BMJ. 1994;309:1395–400.

    PubMed  CAS  Google Scholar 

  5. Callaghan N. The migraine syndrome in pregnancy. Neurology. 1968;18:197–9.

    PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  7. Chen TC, Leviton A. Headache recurrences in pregnant women with migraine. Headache. 1994;34:107–10.

    Article  PubMed  CAS  Google Scholar 

  8. Maggiono F, Alessi C, Maggino T, et al. Primary headaches and pregnancy. Cephalalgia. 1995;15:54.

    Google Scholar 

  9. Marcus DA, Scharff L, Turk DC. Longitudinal prospective study of headache during pregnancy and postpartum. Headache. 1999;39:625–32.

    Article  PubMed  CAS  Google Scholar 

  10. Sances G, Granella F, Nappi RE, et al. Course of migraine during pregnancy and postpartum: a prospective study. Cephalalgia. 2003;23:197–205.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  13. Davis LE. Normal laboratory values of CSF during pregnancy. Arch Neurol. 1979;36:443.

    PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  15. Levine D, Barnes PD, Edleman RR. Obstetric MR imaging. Radiology. 1999;211:609–17.

    PubMed  CAS  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  17. Kanal E, Gillen J, Evans J, Savitz D, Shellock F. Survey of reproductive health among female MR workers. Radiology. 1993;187:395–9.

    PubMed  CAS  Google Scholar 

  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.

    Article  Google Scholar 

  19. American College of Obstetricians and Gynaecologists Committee Opinion. Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol. 2004;104:647–51.

    Article  Google Scholar 

  20. Lowe SA. Diagnostic radiography in pregnancy: risks and reality. Aust N Z J Obstet Gynaecol. 2004;44:191–6.

    Article  PubMed  Google Scholar 

  21. McCollough CH, Schueler BA, Atwell TD, et al. Radiation exposure and pregnancy: when should we be concerned? Radiographics. 2007;27:909–18.

    Article  PubMed  Google Scholar 

  22. Dineen R, Banks A, Lenthall R. Imaging of acute neurological conditions in pregnancy and the puerperium. Clin Radiol. 2005;60:1156–70.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  25. Ramachandren S, Cross BJ, Liebeskind DS. Emergent headaches during pregnancy: correlation between neurologic examination and neuroimaging. Am J Neuroradiol. 2007;28:1085–7.

    Article  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  28. Urbanski PK. How does hydration affect preterm labor? AWHONN Lifelines. 1997;1:25.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  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.

    PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  37. Maizels M, Geiger AM. Intranasal lidocaine for migraine: a randomized trial and open-label follow-up. Headache. 1999;39:543–51.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  40. Von Seggern RL, Adelman JU. Practice and economics cost considerations in headache ­treatment. Part 2: acute migraine treatment. Headache. 1996;36:493–502.

    Article  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  46. Wojnar-Horton RE, Hackett LP, et al. Distribution and excretion of sumatriptan in human milk. Br J Clin Pharmacol. 1996;41:217–21.

    Article  PubMed  CAS  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  48. Kligler B, Chaudhary S. Peppermint oil. Am Fam Phys. 2007;75:1027–30.

    Google Scholar 

  49. Jürgens TP, Schaefer C, May A. Treatment of cluster headache in pregnancy and lactation. Cephalalgia. 2009;29:391–400.

    Article  PubMed  Google Scholar 

  50. Giraud P, Chauvet S. Cluster headache during pregnancy: case report and literature review. Headache. 2009;49:136–9.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  52. Panagariya A, Maru A. Cerebral venous thrombosis in pregnancy and puerperium – a prospective study. J Assoc Physicians India. 1997;45:857–9.

    PubMed  CAS  Google Scholar 

  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. 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.

    Article  CAS  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  56. Katz VL, Peterson R, Cefalo RC. Pseudotumor cerebri and pregnancy. Am J Perinatol. 1989;6:442–5.

    Article  PubMed  CAS  Google Scholar 

  57. Koontz WL, Herbert WP, Cefalo RC. Pseudotumor cerebri in pregnancy. Obstet Gynecol. 1983;62:324–7.

    Article  PubMed  CAS  Google Scholar 

  58. Evans RW, Lee AG. Idiopathic intracranial hypertension in pregnancy. Headache. 2010;50:1513–5.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  60. Coutinho JM, Ferro JM, Canhão P, et al. Cerebral venous and sinus thrombosis in women. Stroke. 2009;40:2356–61.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  62. Griffith JD, Mycyk MB, Kyriacou DN. Metoclopramide versus hydromorphone for the ­emergency department treatment of migraine headache. J Pain. 2008;9:88–94.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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 

Download references

Author information

Authors and Affiliations

  1. Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA

    Dawn A. Marcus MD (Professor)

  2. Dean Health Systems, Madison, WI, USA

    Philip A. Bain MD

Authors
  1. Dawn A. Marcus MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Philip A. Bain MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dawn A. Marcus MD .

Rights and permissions

Reprints and permissions

Copyright information

© 2012 Springer Science+Business Media, LLC

About this chapter

Cite this chapter

Marcus, D.A., Bain, P.A. (2012). Treatment of Pregnant and Breastfeeding Patients with Acute Headache in the ED. In: Practical Assessment and Treatment of the Patient with Headaches in the Emergency Department and Urgent Care Clinic. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-0002-8_6

Download citation

  • DOI: https://doi.org/10.1007/978-1-4614-0002-8_6

  • Published:

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4614-0001-1

  • Online ISBN: 978-1-4614-0002-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation