From the Guidelines
The management of headaches at 28 weeks gestation should prioritize paracetamol as the first-line medication for acute treatment, given its relatively safe profile during pregnancy, as noted in the study published in Nature Reviews Neurology 1. When considering the management of headaches at 28 weeks gestation, it's crucial to identify the cause and severity of the headache.
- Non-pharmacological approaches should be tried first, including:
- Adequate hydration
- Rest in a dark, quiet room
- Cold compresses
- Stress reduction techniques
- If these measures are ineffective, paracetamol (500-1000mg every 6 hours, not exceeding 4g daily) is recommended as the first-line medication due to its safety profile during pregnancy, as indicated by 1. Key considerations include:
- Avoiding NSAIDs, except during the second trimester and under strict medical supervision
- Limiting the use of triptans, such as sumatriptan, due to limited safety data, as mentioned in 1
- Metoclopramide can be used for nausea associated with migraine in pregnancy, according to 1 For preventive migraine medications, propranolol or amitriptyline may be considered under specialist supervision due to their relatively safer profiles compared to other options like topiramate, candesartan, and sodium valproate, which are contraindicated, as stated in 1. It's essential to approach headache management during pregnancy with caution, considering the potential risks to the fetus and the importance of regular prenatal care to monitor for complications that may present with headache as a symptom.
From the Research
Management of Headaches at 28 Weeks Gestation
The management of headaches at 28 weeks gestation involves distinguishing between primary and secondary headache disorders.
- Primary headache disorders, such as migraine and tension-type headaches, are common during pregnancy and can often be managed with conservative treatments 2.
- Secondary headache disorders, on the other hand, can be caused by a range of factors, including homeostatic disturbances, hypertensive disorders of pregnancy, vascular problems, space-occupying lesions, and infections 3.
Red Flags for Secondary Headache Disorders
It is essential to identify red flags for secondary headache disorders, which can be remembered using the mnemonic PREGNANT HA:
- Proteinuria
- Rapid onset
- Elevated blood pressure or temperature
- Gestational age in third trimester
- Neurological signs or symptoms
- Altered level of consciousness
- No headache history or known history of a secondary headache disorder
- Thrombocytopenia or thrombocytosis
- High liver function tests or CRP
- Agonizingly severe pain 3
Diagnostic Evaluation
A diagnostic evaluation should be performed to rule out secondary causes of headache, particularly if red flags are present.
- This may involve laboratory tests, such as complete blood count, liver function tests, and urinalysis 3.
- Imaging studies, such as magnetic resonance imaging (MRI), may also be necessary to evaluate for secondary causes of headache, particularly if the headache occurs late in pregnancy or in the peripartum period 4.
Treatment Options
Treatment options for headaches during pregnancy depend on the underlying cause and severity of the headache.
- Conservative treatments, such as rest, hydration, and over-the-counter pain medications, may be effective for primary headache disorders 2.
- More severe headaches or secondary headache disorders may require more aggressive treatment, such as hospitalization and consultation with a neurologist or other specialist 5.