Reglan and Benadryl for Postpartum Headaches
Metoclopramide (Reglan) and diphenhydramine (Benadryl) can be used as adjunctive therapy for postpartum headaches, particularly when nausea is present, but they should not be first-line treatments. Instead, acetaminophen and NSAIDs should be tried first for most postpartum headaches 1.
First-Line Treatment Options
- Acetaminophen (paracetamol) is the safest first-line medication for postpartum headaches, especially for breastfeeding mothers 2
- NSAIDs such as ibuprofen are recommended by the American College of Obstetricians and Gynecologists (ACOG) as first-line treatment for postpartum pain after vaginal delivery 1
- For more severe pain after cesarean delivery, ACOG recommends a stepwise approach starting with acetaminophen and NSAIDs before considering other medications 1
Role of Metoclopramide (Reglan) in Postpartum Headache Management
- Metoclopramide can be used as adjunctive therapy with simple analgesics, NSAIDs, or ergotamine derivatives 3
- It has moderate efficacy (rated 2 out of 4) for migraine management 3
- Metoclopramide is particularly useful for headaches with associated nausea 2
- Contraindications include pheochromocytoma, seizure disorder, GI bleeding, and GI obstruction 3
- Potential adverse reactions include restlessness, drowsiness, diarrhea, muscle weakness, and dystonic reactions 3
Role of Diphenhydramine (Benadryl) in Postpartum Headache Management
- While not specifically mentioned in the guidelines for postpartum headache management, diphenhydramine may help with sleep and as an adjunct for nausea
- Its sedative properties may be beneficial for tension-type headaches, which are common postpartum (47% of cases) 4
- Caution should be used due to potential sedation, which may impact the mother's ability to care for the newborn
Diagnostic Considerations for Postpartum Headaches
- Postpartum headaches have multiple potential causes and should be evaluated systematically using the PARTUM mnemonic 5:
- Pressure (blood pressure for pre-eclampsia/eclampsia)
- Anaesthetic (post-dural puncture headache)
- Reversible (vasoconstriction syndrome)
- Thrombosis (cerebral venous sinus thrombosis, ischemic stroke)
- Use your brain (other causes)
- Migraine
- Tension-type/migraine headaches (47%), preeclampsia/eclampsia (24%), and spinal headaches (16%) are the most common causes of postpartum headaches requiring hospitalization 4
- Persistent headaches or those with neurological deficits require cerebral imaging to detect potentially life-threatening causes 4
Cautions and Considerations
- Medication overuse headache can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1, 2
- Ergotamine and ergot alkaloids are contraindicated during pregnancy and should be used with caution in the postpartum period 1
- Opioids and butalbital-containing medications should be limited due to risks of dependency and medication-overuse headache 1, 2
- Post-dural puncture headache should be considered in women who received epidural anesthesia during labor 6
- For women with frequent and disabling migraines postpartum, propranolol has the best safety profile if preventive medication is required 1, 2
Treatment Algorithm for Postpartum Headaches
- Rule out secondary causes requiring urgent intervention (preeclampsia, post-dural puncture, cerebral venous thrombosis) 5, 4
- For primary headaches, start with acetaminophen and/or NSAIDs 1
- Add metoclopramide (Reglan) 10 mg orally or IV if nausea is present 3, 2
- Consider diphenhydramine for nighttime use if sleep disturbance is contributing to headaches
- For severe migraines unresponsive to above measures, consider sumatriptan (safe during breastfeeding) 2
- For post-dural puncture headache, consider anesthesia consultation for potential blood patch 4, 6
- For persistent or worsening headaches, especially with neurological symptoms, obtain neuroimaging 4