A 14‑week pregnant woman requests a sick‑leave certificate for new‑onset erythematous ears and headache; what evaluation and management, including safe medications and appropriate duration of work absence, are recommended?

Evaluation and Management of Red Ears and Headache at 14 Weeks Gestation

This patient requires urgent blood pressure measurement and urinalysis to rule out early-onset preeclampsia before attributing symptoms to benign causes, and acetaminophen 1000 mg is the only safe first-line medication for headache relief at this gestational age. 1, 2, 3

Immediate Clinical Evaluation Required

Red Flag Assessment

• Measure blood pressure immediately – any new headache in pregnancy with hypertension must be considered preeclampsia until proven otherwise, even at 14 weeks gestation 1, 2, 3
• Obtain urinalysis for proteinuria – new-onset headache with proteinuria ≥0.3 g/24h or ≥30 mg/mmol defines preeclampsia 1
• Assess for severe preeclampsia features: right upper quadrant/epigastric pain, visual disturbances, hyperreflexia with clonus, or altered mental status 1
• Order complete blood count and liver function tests if any concerning features present – thrombocytopenia or elevated liver enzymes indicate HELLP syndrome 1, 3

Key Clinical Pitfall

While red ear syndrome can present with migraine 4, the absence of prior headache history in this patient is itself a red flag requiring workup for secondary causes 3. The mnemonic PREGNANT HA includes "no headache history" as a warning sign 3.

Differential Diagnosis by Priority

Primary Concern: Hypertensive Disorders

• Pre-eclampsia can present before 20 weeks, particularly in women with multiple fetuses, diabetes, or first pregnancy 1
• Gestational hypertension is defined as BP ≥140/90 mmHg developing after 20 weeks, but pre-existing hypertension may be unmasked as the physiological BP drop of early pregnancy resolves 1

Secondary Consideration: Primary Headache with Red Ear Syndrome

• Red ear syndrome presenting with vestibular migraine has been documented, characterized by sudden ear redness with discomfort and burning sensation 4
• However, this remains a diagnosis of exclusion after ruling out dangerous secondary causes 3

Safe Medication Management

Acute Headache Treatment

• First-line: Acetaminophen (paracetamol) 1000 mg – the only medication with acceptable safety profile across all trimesters 2, 5, 6, 7
• Avoid NSAIDs at 14 weeks – ibuprofen is only considered acceptable during the second trimester (roughly 14-28 weeks), and even then carries risks of fetal gastroschisis and should be avoided in first trimester 1, 2, 5
• Metoclopramide 10 mg can be added if nausea is prominent, though data are strongest for second and third trimester use 2, 5, 6

Medications to Absolutely Avoid

• Oral decongestants – increase risk of fetal gastroschisis and maternal hypertension 1
• Aspirin and NSAIDs – risk of premature ductus arteriosus closure, intrauterine growth restriction, and perinatal mortality 1
• Ergotamine derivatives – contraindicated due to oxytocic properties 2, 5
• Opioids and butalbital – risk of dependency, rebound headaches, and fetal harm 2, 5, 6

Non-Pharmacological Management

Lifestyle Modifications (First-Line Approach)

• Maintain adequate hydration with regular fluid intake throughout the day 2, 5, 6
• Ensure regular meals to avoid hypoglycemia as a migraine trigger 2, 5, 6
• Optimize sleep patterns – consistent, sufficient sleep (7-9 hours) 2, 5, 6
• Identify and avoid specific triggers through headache diary 2, 5, 6
• Apply ice packs to affected areas and rest in quiet, dark environment 2

Work Absence Duration Recommendations

If Preeclampsia is Ruled Out

• 2-3 days sick leave is reasonable for new-onset headache requiring evaluation and symptom control 7
• Return to work when headache resolves and patient can function without requiring frequent acute medication 2

If Preeclampsia is Confirmed

• Immediate referral to obstetrics – this is an obstetric emergency requiring specialist management 1, 3
• Work absence duration determined by obstetric team based on severity and management plan 1

Follow-Up Plan

If Initial Workup is Normal

• Schedule follow-up in 1 week to reassess symptoms and blood pressure 1
• Educate on warning signs: severe headache, visual changes, right upper quadrant pain, decreased fetal movement (when applicable), or seizures requiring immediate emergency evaluation 1, 3
• Limit acetaminophen use to <15 days per month to prevent medication overuse headache 2, 5

When to Consider Preventive Therapy

Preventive treatment should only be considered if patient develops ≥2 disabling attacks per month lasting ≥3 days, or if acute treatments fail 2, 5. Propranolol 80-160 mg daily is the only acceptable preventive option in pregnancy, though ideally avoided in first trimester due to intrauterine growth restriction risk 2, 5, 6.

Documentation for Sick Leave Certificate

Include specific findings:

• Blood pressure measurement and result 1
• Presence or absence of proteinuria 1
• Headache characteristics and associated symptoms 3
• Recommended work absence duration with clear return-to-work criteria 7
• Follow-up plan and warning signs for emergency evaluation 1, 3