Headaches

Question 1

What are causes of HAs in pregnancy?

Answer 1

1) hormonal changes
2) increase in blood volume
3) tension
4) postural changes
5) muscle strain
6) preeclampsia (3rd tri)

Question 2

List the types of primary HAs

Answer 2

1) migraines
2) tension
3) cluster
4) PP

Question 3

Describe the pathophysiology of migraines

Answer 3

neuro dysfunction –> decreased cortical blood flow –> vascular and meningeal receptor activation –> trigeminal sensory neurons stimulated

Question 4

List the types of migraines

Answer 4

1) w/out aura: unilateral, throbbing, N/V, photophobia
2) w/ aura: reversible in 5-60mins; can occur w/out HA
3) chronic: migraine 15 days/mo for >3mo

Question 5

What is the course of migraines in pregnancy?

Answer 5

decrease in 2nd and 3rd tris

*increased risk of preeclampsia

Question 6

How can migraines be treated pharmacologically?

Answer 6

1) acetaminophen as soon as sx start
2) acetaminophen + metoclopramide (Reglan) or compazine 10mg
3) acetaminophen + codeine 30mg
4) acetaminophen + caffeine
5) Fioricet = butalbital + acetaminophen + caffeine
6) antiemetics (e.g. Compazine)
7) triptans = a last resort
8) opioids = ultra last resort; can worsen N/V/C

Question 7

Which meds can cause rebound migraines?

Answer 7

1) acetaminophen + codeine: if using >9days/mo –> neuro consult; neonatal abstinence syndrome
2) Fioricet: no >4-5days/mo

Question 8

How should severe migraines be treated?

Answer 8

1) IV hydration
2) IV antiemetics
3) IV mag
4) Benadryl
5) Compazine
6) +/- short-term narcotic or Botox

Question 9

What is the max dose of acetaminophen?

Answer 9

4g per day

Question 10

What should meds should be avoided in tx of migraines?

Answer 10

ergots (vasoconstriction of uterine vessels –> abortion) + NSAIDs

Question 11

How should pts be educated w/ Fioricet use?

Answer 11

contains acetaminophen, so do not take more on top of that!

Question 12

What is the most common type of HA in pregnancy?

Answer 12

tension-type

Question 13

List the tension-type HA categories

Answer 13

1) infrequent episodic
2) frequent episodic
3) chronic

Question 14

infrequent episodic 
(tension-type)

Answer 14

• 10-12/year or <1/mo
• last 30min - 7 days
• 2+ characteristics: B/L, non-pulsating, mild/moderate, not worse w/ activity
• N/V not attributed to another disorder
• photophobia or phonophobia

Question 15

frequent episodic
(tension-type)

Answer 15

• ≥10 episodes/mo on 1-14 days/mo for at least 3mo
• last 30 mins - 7 days
• 2+ characteristics: B/L, non-pulsating, mild/moderate, not worse w/ activity
• N/V not attributed to another disorder
• photophobia or phonophobia

Question 16

chronic

tension-type

Answer 16

• ≥15days/mo for at least 3 mo
• last 30 mins - 7 days; lasts hours or is continuous
• 2+ characteristics: B/L, non-pulsating, mild/moderate, not worse w/ activity
• N/V not attributed to another disorder
• photophobia, phonophobia, mild nausea

Question 17

What is pharmacological tx for tension HAs?

Answer 17

1) acetaminophen
2) acetaminophen 500mg + caffeine 100mg
3) acetaminophen + codeine 30mg
4) Fioricet

Question 18

What are non-pharm tx for migraines and tension HAs?

Answer 18

1) regular, adequate sleep
2) relaxation: meditation, breathing, progressive relaxation
3) CBT
4) physical therapy: massage, TENS, chiropractics heat/cold
5) biofeedback
6) diet (dec tyramines, alcohol, chocolate)
7) HA diary - avoid triggers
8) magnesium 400mg/day prophylaxis

Question 19

cluster HA presentation

Answer 19

• unilateral
• severe
• explosive
• felt in face and eyes
• 15min - 3h
• watery eyes, stuffy nose, sweating
• ANS dysfunction, agitation

*pre-existing cluster HAs should be referred to neuro

Question 20

What is pharmacological management of cluster HAs?

Answer 20

1) O2 can eradicate
2) sumatriptan
3) topical lidocaine (gel) inside nostril on affected side of head
3) preventative tx
- verapamil
- glucocorticoids

*does not respond to non-pharm tx

Question 21

What do PP HAs occur?

Answer 21

in first week, very common

Question 22

What are PP HA differentials?

Answer 22

• preeclampsia
• anesthesia complications
• CVT
• PP angiopathy

Question 23

List the reasons for secondary headaches

Answer 23

1) idiopathic intracranial HTN (IIH)
2) central vein thrombosis
3) subarachnoid hemorrhage
4) reversible cerebral vasoconstriction syndrome

….infection, substance abuse, withdrawal, trauma, tumor, encephalitis, psych disorder

Question 24

idiopathic intracranial HTN

patho

Answer 24

unknown

elevated prolactin found in CSF

Question 25

IIH presentation

Answer 25

• subacute onset, daily
• papilledema (may be worse lying down and/or in morning)
• horizontal diplopia
• transient visual obscurations
• pulsatile tinnitus

Question 26

IIH complications

Answer 26

permanent vision loss

no risk to pregnancy/fetus

Question 27

central vein thrombosis

Answer 27

• most common PP*
  patho: hypercoagulability
  presentation: similar to IIH
• AVOID CONTRACEPTION*

Question 28

subarachnoid hemmorhage (SAH)

Answer 28

patho: can be caused by aneurysm or by arteriovenous malformations
presentation: “thunderclap” HA

Question 29

reversible cerebral vasoconstriction syndrome

Answer 29

“thunderclap” HA

Question 30

emergency HA sx

Answer 30

• thunderclap HA
• focal neuro deficits
• seizure
• change in consciousness
• vomiting
• stiff neck
• “worst HA of my life”

Question 31

What are risks associated w/ migraine HAs?

Answer 31

• severe migraines <8wk: fetal limb-reduction defects
• MI
• CV disease
• venous thromboembolism
• preeclampsia, HTN

Question 32

When should pts be sent to the PEC?

Answer 32

HA at >20wk GA

present w/ diffuse pain, constant, throbbing, blurred vision, epigastric pain, edema

Question 33

S
N
O
O
P

Answer 33

S ystemic sx (illness or condition, e.g. fever)
N euro sx (altered mental status, change in vision, seizures)
O nset = new, sudden, severe
O ther associated features (e.g. trauma, illicit drug use, awakens from sleep)
P revious hx HA w/ change in sx