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Headache in pregnancy
- 1. Headache in pregnancy Prof. M.C.Bansal. MBBS.,MS.,FICOG.,MICOG. Ex Principal & Controller Jhalawar Medical College & Hospital Jhalawar. MGMC&hospital ,sitapura, Jiapur.
- 2. Introduction 99 % 0f women will experience some degree of headache at some time during 9 months long duration of pregnancy and / during puerparium. One third of them usually develop in mid trimester. 95 % of headache reported in pregnancy are benign in nature, but fear of some serious intracranial cause always drive them for seeking consultation. These Women with primary headache will have migraine in 2/3rd cases while remaining 1/3rd will be suffering from tension headaches.
- 3. It isimportant to remember that pregnancy often a time of profound changes in woman's life . This may cause emotional stress and broken sleep may cause tiredness ----- headache precipitated by domestic problems due to feeling of over burden and non cooperative attitude of family members.
- 4. Path physiology ofheadache Pain of headaches is thought to arise in a wide spread network of sensory fibers that surrounds intracranial blood vessels. These sensory fibers originate in trigeminal ganglia and are found in adventitious layer of all intracranial blood vessels. Headache may result from direct stimulation causing direct pain or secondary inflammatory effects of vasoactive neuropeptides released after stimulation of the sensory fibres.
- 5. Pathophysiology------------ Sex hormonesin particular estrogen ,influence this system directly or in directly modifying cerebral blood flow or neuro peptides. Because of this complicated interaction there are many variables potential points for intervention for treatment. This also explains , why so many varieties of drugs with different mode of actions are available and are effective in some cases of headaches but not in other.
- 6. classification of headachein Pregnancy International headache society Primary headaches-- 1. Migraine 2. Tension headache 3. Cluster( uncommon in pregnancy ) 4. Primary headaches associated with , fever, cough, exertion and sinusitis etc.
- 7. Classification of Headache-------- Secondary Headache— 1. Post head and neck injury. 2. Vascular disorder. ( imminent Eclampsia , sub arachnoid hemorrhage, acute ischaemic stroke ) 3. Non vascular Intra cranial disorders. (idiopathic Intra cranial hypertension, tumors, post dural puncture,) 4. Drug with drawl headache ( substance abuse— alcohol, caffein , cocain, tobacco, drug habituation - then with drawl ) 5. Disorder of homeostasis( hypoglycemia, hypoxia) 6. Disorders of cranial structures (toothache, jaw pain, sinusitis.) 7. Psychiatric ( anxiety , depression, insomnia ,drug with drawl ) 8. Neuralgias ( trigeminal ,Bell’s palsy )
- 8. Clinical Assessment--Interrogation As with any pain , when assessing headache, the quality, location, severity, time, course and exacerbating or relieving factors should be fully evaluated. Ask for any associated neurological symptoms like numbness, tingling, loss or alteration in sensations or movements. Enquire about systemic disturbances such as fever , anorexia, or skin rash. A complete medication history should be taken to rule out medication overuse / with drawl , any drug being given for pre existing headache(its dose , effectiveness , duration, side effects or reason for stopping it ).
- 9. Clinical Examination--- Examination should start with blood Pressure recording and brief gen. Physical examination .,with particular attention to throat and sinuses, stiffness of neck, fever, if focal neurological symptoms – do examination. The family member should be asked about any change in mental state , personality, behavior. The level of consciousness and cognitive ability to be assessed during history taking and examination. ENT , eye examination including fundoscopy .
- 10. Sudden onset. Change in pattern of chronic headache. Neurological signs and symptoms. Change in the level of consciousness , personality or cognition. Meningism. History of recent trauma (head / neck ) Hypertension or endocrine disease. Features suggestive of underlying Pathology with headache in Pregnancy.
- 11. Investigation Why &When ? After appropriate history and neurological examination, absence of any warning features described in previous slide, , absence of persistent neurological signs and symptoms and headache resolves with simple Nsaids ., then she can be followed clinically without investigating. Investigations are required if there is suspicion of any under lying cause of headache. Purpose of investigating such women is to have defined diagnosis , to rule out diseases that may complicate the headache or its treatment e.g. diabetes , pre eclampsia, HTN ,intra cranial tumors etc.
- 12. Investigations------ A .Thenature and extend of investigation shell be decided by clinical possibilities after detailed history taking and thorough clinical examination. B .Exclude 1. pre eclmpsia—HTN, Edema, Albuminuria in pregnancy. 2. Cerebral thrombosis-hyper coagulative states like eclampsia or thrombophilia. Blood should be taken for complete cont, LFT, Urea, s. creatinine ,electrolytes, BT,CT,PT,partial thromboplastin time and thrombophilia screen. 3. Intra cranial hemorrhage –eclampsia , rupture of Berry’s aneurism , accidental hemorrhage. 4. EEG, CT, MRI. For neurological cause if any suspected.
- 13. Investigations------- Lumbar punctureIt is needed in number of clinical conditions complicating pregnancy. Severe headache –with suspicion of meningitis / sub arachnoids hemorrhage. Severe recurrent rapid onset headache. A progressive headache with little or no remission. An atypical headache disorder. Note to be done after consulting neurophysician , when papilloedema present, or fever with neck rigidity --- suspicion of meningitis.
- 14. Investigations--- Radiological studies- No contrast Ct is recommended in 1st trimester., though it is superior to MRI for assessment of bony structures and detection of acute intracranial hemorrhage, but its sensitivity declines as time passes from initial bleeding. for other indications including angiography ,MRI is preferred . Though there is no evidence of harmful effect, MRI is not recommended in 1st trimester. It is believed that foetal exposure up to 5 rads does not result in abortion , anomalies or IUGR. Exposure to uterus from standard CT scan for head and spine is < 1rad.shelding of uterus with lead will furthe protect the foetus. MRI does not use ionizing radiations.
- 15. Primary Headaches 1. Migraine—>It is usually a unilateral ,throbbing, aggravated by activity and associated aura, nausea , vomiting, photophobia , phonophobia( sound sensitive ) .It lasts for hours to days and often develops in a crescendo pattern . Classic migraine with aura is less common and less disabling than that with out aura. Aura is a neurological phenomenon which precede the headache by less than 1hour and lasts for < 15-20 minutes. , typically visual disturbances with scotoma , flash of light ,less common loss of field of vision. Tingling, numbness or speech changes may also develop.post headache woman feels exhausted, stiff neck and fatigued.
- 16. Primary Headache---Migraine--- Diagnosisof migraine can be made when pt had 4-5 episodes of such headaches . 70- 80 % women have considerable improvement in their migraine probably due to sustained rise in estrogen level. 60% of such women redevelop migraine in post partum period. Migraine developing de novo in pregnancy should we diagnose after excluding the more serious neurological causes of headache.
- 17. Primary Headache----tension Type 2. Tension types of Headaches They are not affected by activity. Often diffuse and bilateral. May be localized to head or neck. No associated aura, nausea or vomiting. But some time photophobia / phonophobia may be present with neck stiffness or diffuse headache . Typical description include ― a tight band around my head or my head in a vice ― They are worse in evening with rising tension , may last for hours to days., if last longer ---called chronic Tension headache. Reports both of improving / unchanged in pregnancy are available.
- 18. Secondary Headaches 1. Head Trauma Common , following the road side vehicular accident / domestic violence resulting in direct injury to head and brain tissue. Domestic violence is reported to increase 3-4 folds in pregnancy. 2. Vascular disorders A. Hypertension in pregnancy— Headache in pre eclampsia is due to arterial spasm leading to cerebral ischaemia or and hypertensive encephalopathy. Headache usually bilateral, throbbing increases with activity and rise in B.P., may be followed by blurring of vision, flashing light ,scotoma , epigastric pain ( indicating impending eclampsia (fits). Hence there is Urgent need for seizure prophylaxis .
- 19. Secondary Headache 3. Benign Intracranial Hypertension— 10 times more common in obese women of child bearing age. It may be pre existing or may develop de novo in pregnancy. It is syndrome with symptoms and signs of raised intra cranial B.P. with out a cause detectable on CT or MRI studies. It may be due to increased production or decreased resorption of CSF. It presents with global headache that may be worse in lying down position , progressive dipolpia or impaired vision---if untreated.10 % risk of permanent vision impairment. testing for diplopia, impaired vision and field of vision along with Lumber puncture---abnormally raised opening pressure of CSF. No increased risk to mother and foetus in pregnancy. Associated cerebral vein thrombosis need to be excluded with the help of MRI.
- 20. Secondary Headache-----Vascular type- B. Brain Haemorrhage- (a)subaracnoid haemorrhage - the classical presentation ofsub arachnoid haemorrhage is the sudden onset of sever incapacitating headache , neck rigidity and collapse. - 50% cases will have less dramatic presentation with a progressive , severe un remitting headache. -subarachnoid haemorrhage account for 50% cases of cerebral haemorrhage and carry 50% mortality. - subarachnoid caused by rupture of either of an intracranial vascular malformation / saccular or berry aneurism.Its incidence being 1: 10 000 in pregnancy .
- 21. Secondary Headache----Vascular type—Brain Haemorrhage----------- ( b) Intracerebral haemorrhage-- Rare event that may be common in pregnancy. Presents with sudden and severe headache with progressive neurological deficit ( paralysis). in pregnancy it develops as complication of gestational hypertensive disease or secondary to cocaine and alcohol abuse. If mother is clinically stable the diagnostic work up should begin with a brain CT . If it is not helpful Lumber puncture is advocated to look for blood in CSF. however in deteoriatng state of patient often requires neurological intervention and delivery of baby to decrease risk to mother and child.
- 22. (c) Cerebral Vein Thrombosis – -Although still rare , the risk of cerebral stroke in young women increases 13 folds in pregnancy. - Cerebral vein thrombosis being the most common cause ----hypercoagulable state in pregnancy more when eclampsia or underlying throbophillia is present. - Usual presentation with focal neurological symptoms and signs. - Superior sagittal sinus thrombosis presents with severe headache without focal neurological signs , may be associated with rise in B.P.---PET / post eclampsia paresis maybe confusing. Immediate Heparinization and hydration shell be started soon. Secondary headache –vascular Type---Cerebral Vein Thrombosis
- 23. Secondary Headache Brain Tumor-- Pregnant women with severe / new headache may be afraid of having brain tumor. Only 50% brain tumors are presenting with headache and that too of mild degree. Pregnancy does not increase the risk of developing brain tumors. It may worsen the pre existing symptoms if Tumors are of vascular nature , meningiomas or acaustic neuromas. Curative Surgery can be performed in 2nd trimester.ss
- 24. Post Partum headache 40% delivered women develop headache in 1st week postpartum. The cause in uncertain but women having pre existing migraine may develop it due to sudden drop in estrogen level. 15 % women may have spinal headache(low / high tension) secondary to spinal anaesthesia and 1-2% after epidural puncture for pain less normal delivery., need appropriate treatment. A few of them may have headache due to septic meningitis or subdural haematoma.
- 25. Headaches due toSystemic or other causes Hypoglycaemia with the treatment and fever due to intercurrent infection . consumption of Chocolate , cheese , processed meat , chinese restaurant headache, alcohol etc. Withdrawal from elicit drugs e.g. amphetamines , barbiturate , cocaine, opiates and cocaine.