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Effective Health Care Program

Management of Primary Headaches in Pregnancy

Key Questions Draft

Draft Key Questions

  1. What are the harms or comparative harms of treatments for migraine or other headaches during pregnancy?
  2. What are the harms comparative harms of interventions to prevent migraine during pregnancy?
  3. What is the effectiveness or comparative effectiveness of treatment for migraine for women during pregnancy?
  4. What is the effectiveness or comparative effectiveness of interventions to prevent migraines for women during pregnancy?

Contextual question: What is the effectiveness (comparative effectiveness) of interventions to prevent or treat migraines in the general population

Draft Analytic Framework

Figure 1. Draft Analytic Framework for Headache in Pregnancy

 Figure 1: This figure depicts the key questions within the context of the PICOTS described in the previous section. In general, the figure illustrates how pharmacologic treatment may result in outcomes such as symptoms, quality of life and adverse events that may occur at any point after the treatment is received.

Background

When a pregnant patient presents with a headache, the clinician must first distinguish between a primary headache (when pain is the disease) from a secondary headache (when pain is a symptom of another disease). The decisional dilemma revolves around how to make this distinction so as to begin therapy that is not only effective but also safe for the mother and developing baby.1 Primary headache disorders are classified as migraines (acute, chronic), tension headaches or cluster headaches. Secondary headaches may arise from pre-eclampsia/eclampsia, changes in hormones, hydration, and sleep patterns or later during the postpartum period from anesthesia (post-dural puncture headache). In any woman, serious secondary causes of headache can include neurologic emergencies such as intracranial hemorrhage, cerebral venous thrombosis, and pituitary apoplexy.

Primary headaches are common in pregnancy. In US and international studies, 12–29% of pregnant women met migraine diagnostic criteria, and another 10–16% reported non-migraine headaches.2,3 Although most headaches during pregnancy are not life-threatening, they exact a toll on quality of life and maternal-child bonding.1

There is a notable lack of current guidance on managing primary headaches in pregnancy. The American College of Obstetricians and Gynecologists (ACOG) has not previously published any committee opinions or practice bulletins for any headache topics, and are eager to remedy this gap. The AAP/ACOG publication "Guidelines for Perinatal Care. 2017" mentions headache as a complication of infection, pre-eclampsia, and neuroaxial anesthesia, but does not mention diagnosis, prevention or treatment of primary headaches.4 The American Headache Society has not published any guidance for pregnant women. Three recent American Headache Society guidelines based on their own reviews do not mention pregnant women: migraine prophylaxis in 2015,5 pharmacologic treatment of acute migraine in the emergency department in 2016,6 and treatment of cluster headache.7

There are two significant clinical decisional dilemmas: first, clinicians need guidance on how to quickly and accurately diagnose whether a headache is due to a serious etiology, while weighing the risks and benefits of available imaging and diagnostic tests in pregnancy. Although such guidance is lacking, the lack of primary literature makes this task impossible at present. Practitioners will have to rely on non-systematic reviews and expert opinion.1,8-10

Secondly, clinicians need guidance on the relative benefits and harms of treatment options for primary headaches to improve the quality of life for pregnant women while minimizing risk of adverse effects for her and the baby.

Without current guidance for how to treat headaches in pregnancy, practitioners may generalize evidence on treatment or prevention for headache from the general population and apply it to pregnant populations. However, harms of interventions in pregnancy may be different from the general population, therefore the first two questions (KQ 1 and 2) focus on the harms of interventions for treatment and prevention. In searching for harms, the exposure to the medication is more important than the type of headache that needed treatment, and the therapies for migraine and other headache types overlap.

Additionally, practitioners need to balance benefits and harms. While we included KQ3 and KQ4, we recognize that there may little high quality evidence of effectiveness of treatments (KQ3) or prevention (KQ4) of headaches in pregnancy. Therefore, we also included a contextual question about effectiveness and comparative effectiveness in the general population so that practitioners and guideline developers can use this review to help in decision-making.

PICOTS

Key Questions

KQ1, KQ3: treatment

KQ2, KQ4: prevention

Population

KQ1, KQ3:

Pregnant, postpartum, or breastfeeding women with new or pre-existing:

  • Migraine
  • Other primary headache

KQ2, KQ4:

Pregnant, postpartum, or breastfeeding women with prior history of

  • Migraine
  • Other primary headache

Interventions

KQ1, KQ3:

Pharmacologic

  • acetaminophen, anti-emetics, antihistamines, caffeine, magnesium, NSAIDs, OTC analgesic,
  • triptans, narcotics, bultalbitol

Non-pharmacologic (hydration, physiotherapy, others)

KQ2, KQ4:

Pharmacologic

  • verapamil, prednisolone
  • others

Non-pharmacologic (hydration, physiotherapy, others)

Comparators

Other treatment, placebo, No intervention

Other treatment, placebo, No intervention

Outcomes

Symptom severity, Resolution

Maternal Adverse events

Fetal/Infant

  • Death
  • Preterm birth/low birthweight
  • Congenital anomalies
  • Perinatal complications (low APGAR, withdrawal, respiratory distress, NICU time)
  • Poor infant attachment/bonding
  • Delayed social, emotional and cognitive development

Occurrence rate/frequency, Symptom severity

Maternal Adverse events

Fetal/Infant

  • Death
  • Preterm birth/low birthweight
  • Congenital anomalies
  • Perinatal complications (low APGAR, withdrawal, respiratory distress, NICU time)
  • Poor infant attachment/bonding
  • Delayed social, emotional and cognitive development

Timing

Any

Any

Setting

Any

Any

References

  1. Negro A, Delaruelle Z, Ivanova TA, et al. Headache and pregnancy: a systematic review. J Headache Pain. 2017;18(1):106.
  2. Frederick IO, Qiu C, Enquobahrie DA, et al. Lifetime prevalence and correlates of migraine among women in a pacific northwest pregnancy cohort study. Headache. 2014;54(4):675-685.
  3. Gelaye B, Do N, Avila S, et al. Childhood Abuse, Intimate Partner Violence and Risk of Migraine Among Pregnant Women: An Epidemiologic Study. Headache. 2016;56(6):976-986.
  4. AAP, ACOG. Guidelines for Perinatal Care, 8th Edition. Elk Grove Village, IL: Americal Academy of Pediatrics, American College of Obstetricians and Gynecologists; 2017.
  5. Orr SL, Friedman BW, Christie S, et al. Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache. 2016;56(6):911-940.
  6. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies. Headache. 2015;55(1):3-20.
  7. Robbins MS, Starling AJ, Pringsheim TM, Becker WJ, Schwedt TJ. Treatment of Cluster Headache: The American Headache Society Evidence-Based Guidelines. Headache. 2016;56(7):1093-1106.
  8. Gao G, Zucconi RL, Zucconi WB. Emergent Neuroimaging During Pregnancy and the Postpartum Period. Neuroimaging clinics of North America. 2018;28(3):419-433.
  9. Kanekar S, Bennett S. Imaging of Neurologic Conditions in Pregnant Patients. Radiographics : a review publication of the Radiological Society of North America, Inc. 2016;36(7):2102-2122.
  10. Cozzolino M, Bianchi C, Mariani G, Marchi L, Fambrini M, Mecacci F. Therapy and differential diagnosis of posterior reversible encephalopathy syndrome (PRES) during pregnancy and postpartum. Archives of gynecology and obstetrics. 2015;292(6):1217-1223.