Headaches in pregnancy TOG 2014

Question 1

90% of headaches in pregnancy are due to which cause?

Answer 1

Migrane
Tension headache

Question 2

List causes of secondary headache?

Answer 2

Hypertension
Subarachnoid haemorrhage
Drug-related, e.g. nifedipine, medication overuse
Postdural tap (see Box 2)
Meningitis
Cerebral venous thrombosis
Anaemia
Caffeine withdrawal
Idiopathic intracranial hypertension
Stroke
Arteriovenous malformation (can enlarge/bleed in pregnancy)
Enlargement of a pituitary tumour
Enlargement of a hormone-sensitive tumour, e.g. meningioma
Bleeding into a pre-existing tumour
Cerebral metastasis of choriocarcinoma

Question 3

How common is puctue of the dura during epidural

Answer 3

0.5-2.5%

Question 4

If accidental dural puncture occurs, what is the risk of the headache?

Answer 4

70-80%

Question 5

Describe Postural puncture headache, how long do they last?

Answer 5

Usually front-occipital, worse on standing.
Arise 24-48hrs after puncture, typically last for 7-10 days but can last up 6 weeks

Question 6

What is the cure rate of blood patch?

Answer 6

60-90%

Question 7

Description of typical migraine

Answer 7

unilateral
pulsating
builds up over minutes to hours
moderate to severe in intensity
associated with nausea and/or vomiting and/or sensitivity to light and/or sensitivity to sound
disabling
aggravated by routine physical activity.

Question 8

1st line management of migrane

Answer 8

voidance of precipitants, rest, hydration, regular meals and relaxation. Paracetamol and anti-emetics (metoclopramide)

Question 9

If > 3-4 migraines per month which prophylactic medication can be considered

Answer 9

Aspirin 75mg OD
Propranolol 10-40mg TDS, effective >80%
Amitriptyline 25-50mg at night

Question 10

Can 5HT1-receptor agonists (triptans) be used in pregnancy

Answer 10

Unclear safety data.
Do not use in hemiplegic migraine
Can use in isolated cases if no other Tx effective

Question 11

Effect of pregnancy on migranes

Answer 11

50-90% with pre-existing migrants experience improvements during pregnancy, most marked 2nd & 3rd trimester

Question 12

Effect of migraine on pregnancy?

Answer 12

2 fold increase PET
17 fold increased risk stroke
4 fold increase MI

Question 13

Clinical feature of idiopathic intracranial hypertension?

Answer 13

Generalised non throbbing
Aggrevated by coughing/strainng
Diplopia 38%
Visual loss
Papilloedema
CSF pressure increased >20cmH20 on LP

Question 14

Diagnosis idiopathic intracranial hypertension?

Answer 14

Papilloedema
CSF pressure increased >20cmH20 on LP
CT/MRI: No space occupying lesion

Perform imaging before LP

Question 15

Management idiopathic intracranial hypertension?

Answer 15

Limit weight gain
Therapeutic LP
Acetazolamide 500mg BD
Monitor visual fields/acuity

Question 16

What condition is posterior reversible encephalopathy syndrome associated with?

Answer 16

PET

Question 17

What are the clinical features of Posterior reversible encephalopathy syndrome (PRES)

Answer 17

Headache
Vomiting
Visual disturbance - cortical blindness
Seizure
Altered mental state
Oedema in posterior circulation of brain

Question 18

Management Posterior reversible encephalopathy syndrome (PRES)

Answer 18

MgSu

Question 19

Which condition mostly develops in postpartum period and is associated with multifocal arterial constriction and dilatation?

Answer 19

Reversible cerebral vasoconstriction syndrome

Question 20

How does Reversible cerebral vasoconstriction syndrome (RCVS) present?

Answer 20

recurrent sudden onset and severe headaches over 1–3 weeks, often accompanied by nausea, vomiting, photophobia, confusion and blurred vision.

Question 21

How to diagnose Reversible cerebral vasoconstriction syndrome (RCVS)

Answer 21

MR angiography - ‘beading’ appearance with resolution within 1-3 months.

Question 22

Treatment of Reversible cerebral vasoconstriction syndrome (RCVS)?

Answer 22

CCB e.g. nimodipine
High dose steroids
MgSu

Question 23

What is the incidence of cerebral venous thrombosis in pregnancy?

Answer 23

1 in 10,000

Question 24

What proportion of cases occur in pregnancy/postpartum? When most likely to present?

Answer 24

5-20% cases of CVT
Most likely in 3rd trimester - 4 weeks PP

Question 25

Clinical feature of CVT?

Answer 25

Headache - acute/subacute, localised, continous, mod-severe.

Papilloedema, focal deficit, altnered consciousness, seizure, cranial nerve signs.

Question 26

Risk factors for CVT

Answer 26

Same as DVT/PE but especially infection and dehydration

Question 27

Imaging modality to Ix CVT?

Answer 27

CT venogram
MRV or MRI with T2 weighted imaging

Plain CT only abnormal in 30% cases

Question 28

Treatment of CVT

Answer 28

Refer neurology
Anticoagulation - 6 months
Thrombophilia screen
Repeat MRV at 3-6 months
LMWH in next pregnancy

Question 29

What is the accepted background cumulative dose of ionising radiation during pregnancy?

Answer 29

50mGy

Question 30

Fetal expose for CT head?

Answer 30

<0.005mGy

Question 31

When should MRI be avoided?

Answer 31

Avoid in 1st trimester, risk hyperthermia and acoustic noise.

Question 32

Should contrast media be used in pregnancy

Answer 32

Best avoided, if used neonatal thyroid function should be checked

Question 33

Can gadolinium based contrast be used in pregnancy?

Answer 33

Appears to be safe in pregnancy

Question 34

If breastfeeding and receive contrast or gadolinium, can they continue breast feeding?

Answer 34

Yes