How to manage a 6-week pregnant woman with a history of migraine-like headaches, presenting with headache, scalp tenderness, and newly elevated blood pressure (hypertension) of 160/100 mmHg, with no prior history of hypertension?

Management of Hypertension in a 6-Week Pregnant Woman with Headache

This patient with BP 160/100 mmHg, headache, and scalp tenderness requires immediate blood pressure re-evaluation and antihypertensive treatment to reduce maternal and fetal risks.

Initial Assessment and Classification

• This patient presents with severe hypertension (BP 160/100 mmHg) at 6 weeks gestation, which is concerning for pre-existing hypertension since it occurs before 20 weeks gestation 1
• The presence of headache with scalp tenderness, especially with a history of migraine-like headaches, requires careful evaluation as these may be warning signs of severe hypertension or pre-eclampsia 1
• Hypertension in early pregnancy (before 20 weeks) is typically classified as pre-existing hypertension, which complicates 1-5% of pregnancies 1

Immediate Management

• BP ≥160/100 mmHg should be re-evaluated within 15 minutes to confirm the reading, as per guidelines 1
• If confirmed, this level of BP requires prompt antihypertensive treatment as it represents a hypertensive urgency that increases risk of maternal complications including stroke 1
• The immediate goal is to decrease mean BP by 15-25% with a target of SBP 140-150 mmHg and DBP 90-100 mmHg 1

Pharmacological Management

• Labetalol is considered first-line treatment for severe hypertension in pregnancy and can be given orally or intravenously in urgent situations 1
• Oral nifedipine is another appropriate first-line option for urgent BP control in pregnancy 1
• Methyldopa is recommended for long-term management but should not be used primarily for urgent BP reduction 1
• ACE inhibitors, ARBs, and direct renin inhibitors are strictly contraindicated in pregnancy due to fetotoxicity 1

Special Considerations for This Patient

• The history of migraine-like headaches requires attention as there may be a relationship between migraine and hypertension 2
• Poorly controlled blood pressure may exacerbate the frequency and severity of migraine 2
• The patient's current progesterone treatment for IVF should be continued as there's no direct contraindication with antihypertensive therapy 1
• Scalp tenderness at multiple locations is concerning and may represent a neurological symptom that warrants further evaluation 1

Monitoring and Follow-up

• After initial BP control, regular monitoring is essential with a target of maintaining BP <140/90 mmHg 1
• Evaluate for proteinuria to rule out early pre-eclampsia, although this is uncommon before 20 weeks 1
• Monitor for maternal early warning signs including persistent headache, visual disturbances, and changes in mental status 1
• Consider referral to a maternal-fetal medicine specialist for ongoing management of hypertension in pregnancy 1

Prevention of Complications

• Low-dose aspirin (75-100 mg/day) may be considered as prophylaxis if the patient has risk factors for pre-eclampsia 1
• Non-pharmacological measures include limitation of activities and some bed rest in the left lateral position 1
• A normal diet without salt restriction is advised to prevent low intravascular volume 1
• Regular prenatal care with close BP monitoring is essential throughout pregnancy 1

Cautions and Pitfalls

• Avoid excessive BP reduction as this may impair uteroplacental perfusion and jeopardize fetal development 1
• Be vigilant for signs of worsening hypertension or development of pre-eclampsia as pregnancy progresses 1
• Consider the possibility that headache may be related to both hypertension and the patient's history of migraine 2, 3
• Recognize that approximately one-third of patients with high BP may remain undiagnosed and untreated without proper follow-up 4