What evaluation and management are recommended for a pregnant patient at 33 weeks gestation with headaches and sleep disturbances?

Evaluation and Management of Headache and Sleep Disturbances at 33 Weeks Gestation

This patient requires urgent evaluation to exclude preeclampsia, as new headache in a pregnant woman at 33 weeks must be considered preeclampsia until proven otherwise, particularly given the concurrent sleep disturbances which may indicate systemic illness. 1, 2

Immediate Assessment Required

Critical Red Flag Evaluation

• Measure blood pressure immediately – any reading ≥140/90 mm Hg requires urgent workup for preeclampsia, as hypertension with headache in pregnancy is preeclampsia until proven otherwise 1, 2
• Check for proteinuria – dipstick >1+ should be followed by urine albumin-to-creatinine ratio (UACR); UACR ≥30 mg/mmol confirms significant proteinuria 1
• Assess for neurological warning signs – visual disturbances, severe intractable headache, epigastric pain, vomiting, or clonus indicate severe preeclampsia requiring immediate hospital assessment 1

Laboratory Investigations if Preeclampsia Suspected

• Complete blood count (hemoglobin, platelet count) 1
• Liver transaminases 1
• Serum creatinine 1
• Uric acid 1

These tests should be performed at least twice weekly if preeclampsia is diagnosed, as all cases may become emergencies rapidly. 1

If Preeclampsia is Excluded: Primary Headache Management

Acute Headache Treatment

• First-line: Acetaminophen 1000 mg orally – this is the safest option during pregnancy 2, 3, 4, 5
• Second-line (if acetaminophen fails): Ibuprofen 400-800 mg – can be used in the second trimester only; must be avoided in the third trimester due to risk of premature ductus arteriosus closure 2, 4
• For severe refractory migraine: Metoclopramide 10 mg for nausea and headache, safe in third trimester 2, 4
• Avoid completely: Opioids, butalbital, ergotamines, and NSAIDs in third trimester – these carry risks of dependency, rebound headaches, and fetal harm 2, 4

Non-Pharmacological Interventions

• Identify and avoid migraine triggers 2, 4
• Maintain consistent sleep schedule 2, 6, 4
• Stay well hydrated 2, 4
• Eat regular meals 2, 4
• Engage in regular low-intensity physical activity 2, 4
• Consider magnesium supplementation 6

Sleep Disturbance Management

Clinical Significance

Sleep disturbances in pregnancy are associated with increased risk of preeclampsia (OR 2.80), gestational hypertension (OR 1.74), gestational diabetes (OR 1.59), cesarean section (OR 1.47), and preterm birth (OR 1.38). 7 This makes addressing sleep problems clinically important, not just for comfort.

Approach to Sleep Problems

• Prioritize non-pharmacological interventions first – sleep hygiene, consistent sleep-wake schedule, appropriate physical activity 2, 8
• If pharmacological treatment becomes necessary, options are limited and should be discussed with obstetrics, as data on safety are lacking for most sleep medications in pregnancy 8
• Monitor for sleep-disordered breathing – consider evaluation if symptoms of obstructive sleep apnea are present, as this is associated with adverse pregnancy outcomes 1, 7

Common Pitfalls to Avoid

• Never dismiss headache as "just pregnancy-related" without checking blood pressure and proteinuria – missing preeclampsia can lead to maternal stroke, seizures, or death 1
• Do not prescribe NSAIDs at 33 weeks gestation – this is third trimester and NSAIDs must be avoided due to risk of premature ductus arteriosus closure 2, 4
• Avoid opioids for headache treatment – they cause dependency, medication overuse headache, and do not address the underlying problem 2, 4
• Do not ignore sleep disturbances as "normal pregnancy complaints" – they are associated with significant maternal and fetal morbidity and warrant evaluation 7

Medical Certificate Considerations

The patient can be cleared for work/activities only after preeclampsia has been definitively excluded through blood pressure measurement, proteinuria assessment, and clinical evaluation. 1 If preeclampsia is present, hospital assessment is mandatory regardless of symptom severity, as blood pressure level alone does not predict risk of serious complications. 1