Headaches in pregnancy TOG 2014 Flashcards
90% of headaches in pregnancy are due to which cause?
Migrane
Tension headache
List causes of secondary headache?
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
How common is puctue of the dura during epidural
0.5-2.5%
If accidental dural puncture occurs, what is the risk of the headache?
70-80%
Describe Postural puncture headache, how long do they last?
Usually front-occipital, worse on standing.
Arise 24-48hrs after puncture, typically last for 7-10 days but can last up 6 weeks
What is the cure rate of blood patch?
60-90%
Description of typical migraine
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.
1st line management of migrane
voidance of precipitants, rest, hydration, regular meals and relaxation. Paracetamol and anti-emetics (metoclopramide)
If > 3-4 migraines per month which prophylactic medication can be considered
Aspirin 75mg OD
Propranolol 10-40mg TDS, effective >80%
Amitriptyline 25-50mg at night
Can 5HT1-receptor agonists (triptans) be used in pregnancy
Unclear safety data.
Do not use in hemiplegic migraine
Can use in isolated cases if no other Tx effective
Effect of pregnancy on migranes
50-90% with pre-existing migrants experience improvements during pregnancy, most marked 2nd & 3rd trimester
Effect of migraine on pregnancy?
2 fold increase PET
17 fold increased risk stroke
4 fold increase MI
Clinical feature of idiopathic intracranial hypertension?
Generalised non throbbing
Aggrevated by coughing/strainng
Diplopia 38%
Visual loss
Papilloedema
CSF pressure increased >20cmH20 on LP
Diagnosis idiopathic intracranial hypertension?
Papilloedema
CSF pressure increased >20cmH20 on LP
CT/MRI: No space occupying lesion
Perform imaging before LP
Management idiopathic intracranial hypertension?
Limit weight gain
Therapeutic LP
Acetazolamide 500mg BD
Monitor visual fields/acuity
What condition is posterior reversible encephalopathy syndrome associated with?
PET
What are the clinical features of Posterior reversible encephalopathy syndrome (PRES)
Headache
Vomiting
Visual disturbance - cortical blindness
Seizure
Altered mental state
Oedema in posterior circulation of brain
Management Posterior reversible encephalopathy syndrome (PRES)
MgSu
Which condition mostly develops in postpartum period and is associated with multifocal arterial constriction and dilatation?
Reversible cerebral vasoconstriction syndrome
How does Reversible cerebral vasoconstriction syndrome (RCVS) present?
recurrent sudden onset and severe headaches over 1–3 weeks, often accompanied by nausea, vomiting, photophobia, confusion and blurred vision.
How to diagnose Reversible cerebral vasoconstriction syndrome (RCVS)
MR angiography - ‘beading’ appearance with resolution within 1-3 months.
Treatment of Reversible cerebral vasoconstriction syndrome (RCVS)?
CCB e.g. nimodipine
High dose steroids
MgSu
What is the incidence of cerebral venous thrombosis in pregnancy?
1 in 10,000
What proportion of cases occur in pregnancy/postpartum? When most likely to present?
5-20% cases of CVT
Most likely in 3rd trimester - 4 weeks PP
Clinical feature of CVT?
Headache - acute/subacute, localised, continous, mod-severe.
Papilloedema, focal deficit, altnered consciousness, seizure, cranial nerve signs.
Risk factors for CVT
Same as DVT/PE but especially infection and dehydration
Imaging modality to Ix CVT?
CT venogram
MRV or MRI with T2 weighted imaging
Plain CT only abnormal in 30% cases
Treatment of CVT
Refer neurology
Anticoagulation - 6 months
Thrombophilia screen
Repeat MRV at 3-6 months
LMWH in next pregnancy
What is the accepted background cumulative dose of ionising radiation during pregnancy?
50mGy
Fetal expose for CT head?
<0.005mGy
When should MRI be avoided?
Avoid in 1st trimester, risk hyperthermia and acoustic noise.
Should contrast media be used in pregnancy
Best avoided, if used neonatal thyroid function should be checked
Can gadolinium based contrast be used in pregnancy?
Appears to be safe in pregnancy
If breastfeeding and receive contrast or gadolinium, can they continue breast feeding?
Yes
