What is the evaluation and treatment of a pregnant patient presenting with a severe headache in the urgent care setting?

From the Guidelines

The evaluation and treatment of a pregnant patient presenting with a severe headache in the urgent care setting should prioritize paracetamol as the first-line medication for acute treatment of migraine.

Evaluation

• A thorough medical history and physical examination are essential to determine the cause of the headache and rule out other potential causes such as preeclampsia or eclampsia.
• The patient's medication history and any previous diagnoses of migraine or other headache disorders should be considered.

Treatment

• Paracetamol should be used as the first-line medication for acute treatment of migraine in pregnancy, despite its relatively poor efficacy, due to its safer profile compared to other options 1.
• NSAIDs can be used only during the second trimester, but with caution and under strict supervision.
• Triptans, such as sumatriptan, should be used only under the strict supervision of a specialist, as the safety data available are limited and originate from post-marketing surveillance 1.
• For nausea associated with migraine in pregnancy, metoclopramide can be used.
• Preventive migraine medications, such as topiramate, candesartan, and sodium valproate, are contraindicated due to the potential for fetal harm, while propranolol or amitriptyline may be considered under specialist supervision 1.

From the Research

Evaluation of a Pregnant Patient with a Severe Headache

• The differential diagnosis for headache in pregnancy is broad and includes conditions that range in acuity and severity, such as migraine, tension-type headaches, and vascular causes of headache due to hormone changes and increased hypercoagulability in pregnancy 2, 3.
• A careful history, physical examination, and possible diagnostic workup should be performed to exclude organic causes of headache and to confirm the diagnosis 4, 3.
• Physiologic changes induced by pregnancy increase the risk of cerebral venous thrombosis, dissection, and pituitary apoplexy, and preeclampsia, a serious condition unique to pregnancy, must also be considered 2.
• "Red flag symptoms" suggesting that headache is a symptom of a serious disease should be identified, and additional studies such as electroencephalography, ultrasound of the vessels of the head and neck, brain MRI and MR angiography with contrast ophthalmoscopy and lumbar puncture may be necessary 5.

Treatment of a Pregnant Patient with a Severe Headache

• The preferred therapeutic strategy for the treatment of primary headaches should always be a non-pharmacological one, but treatment should not be postponed as an undermanaged headache can lead to stress, sleep deprivation, depression and poor nutritional intake that in turn can have negative consequences for both mother and baby 5.
• If non-pharmacological interventions seem inadequate, a well-considered choice should be made concerning the use of medication, taking into account all the benefits and possible risks, and medications such as acetaminophen and metoclopramide are commonly used 6.
• Medications considered potentially hazardous for fetal health and less effective for migraine, such as opioids and butalbital, should be used with caution, and other treatments that may have low teratogenic risk, such as nerve blocks, IV fluid boluses, and triptans, should be considered 6.
• A standardized approach to the treatment of migraine in pregnancy is needed, and guidelines and protocols should be developed to ensure consistent and safe treatment 6.