title: Headache in pregnancy: an approach to emergency department evaluation and management.
abstract: Headache is a common presenting complaint in the emergency department. The differential diagnosis is broad and includes benign primary causes as well as ominous secondary causes. The diagnosis and management of headache in the pregnant patient presents several challenges. There are important unique considerations regarding the differential diagnosis, imaging options, and medical management. Physiologic changes induced by pregnancy increase the risk of cerebral venous thrombosis, dissection, and pituitary apoplexy. Preeclampsia, a serious condition unique to pregnancy, must also be considered. A high index of suspicion for carbon monoxide toxicity should be maintained. Primary headaches should be a diagnosis of exclusion. When advanced imaging is indicated, magnetic resonance imaging (MRI) should be used, if available, to reduce radiation exposure. Contrast agents should be avoided unless absolutely necessary. Medical therapy should be selected with careful consideration of adverse fetal effects. Herein, we present a review of the literature and discuss an approach to the evaluation and management of headache in pregnancy.
authors.affiliation: Alpert Medical School of Brown University, Department of Emergency Medicine, Providence, Rhode Island.
authors.forename: Jessica C
authors.initials: JC
authors.lastname: Schoen
authors.affiliation: Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota.
authors.forename: Ronna L
authors.initials: RL
authors.lastname: Campbell
authors.affiliation: Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota.
authors.forename: Annie T
authors.initials: AT
authors.lastname: Sadosty
mesh_terms: D003663:Decision Trees; D004636:Emergency Service, Hospital; D004638:Emergency Treatment; D005260:Female; D006261:Headache / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy*; D006801:Humans; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy*
references.citation: Cleve Clin J Med. 2012 Jun;79(6):393-400
references.pmid: 22660870
references.citation: BJOG. 2000 Jul;107(7):833-8
references.pmid: 10901551
references.citation: Am J Med Genet. 1999 Sep 17;86(3):242-4
references.pmid: 10482873
references.citation: Curr Pain Headache Rep. 2010 Apr;14(2):164-73
references.pmid: 20425207
references.citation: J Neurosurg Nurs. 1985 Aug;17(4):230-7
references.pmid: 3849563
references.citation: Stroke. 2012 Jun;43(6):1711-37
references.pmid: 22556195
references.citation: Clin Microbiol Infect. 2012 Apr;18(4):345-51
references.pmid: 21375656
references.citation: BMJ. 2011;343:d4277
references.pmid: 21768192
references.citation: Am J Emerg Med. 1999 Oct;17(6):517-21
references.pmid: 10530526
references.citation: Neurology. 2012 Sep 18;79(12):1230-6
references.pmid: 22955127
references.citation: Anesthesiology. 2012 Feb;116(2):324-33
references.pmid: 22166951
references.citation: Semin Ultrasound CT MR. 2012 Feb;33(1):37-45
references.pmid: 22264901
references.citation: Clin Endocrinol (Oxf). 2004 Dec;61(6):747-52
references.pmid: 15579190
references.citation: Infect Dis Obstet Gynecol. 2009;2009:63624
references.pmid: 17485820
references.citation: Reprod Toxicol. 2009 Jul;28(1):1-10
references.pmid: 19490988
references.citation: Arch Pathol Lab Med. 2006 Apr;130(4):533-5
references.pmid: 16594746
references.citation: Headache. 2009 Jan;49(1):136-9
references.pmid: 19125883
references.citation: Expert Opin Pharmacother. 2004 Jun;5(6):1287-98
references.pmid: 15163274
references.citation: Obstet Gynecol. 2004 Sep;104(3):647-51
references.pmid: 15339791
references.citation: Can J Neurol Sci. 2008 May;35(2):146-52
references.pmid: 18574926
references.citation: J Neurol. 2002 Aug;249(8):1078-81
references.pmid: 12195458
references.citation: Cephalalgia. 2004;24 Suppl 1:9-160
references.pmid: 14979299
references.citation: Birth Defects Res A Clin Mol Teratol. 2012 Jan;94(1):22-30
references.pmid: 22102545
references.citation: Arch Pathol Lab Med. 2002 Apr;126(4):413-5
references.pmid: 11900563
references.citation: BMC Neurol. 2012;12:114
references.pmid: 23020264
references.citation: Am J Obstet Gynecol. 1996 Jun;174(6):1801-5; discussion 1805-6
references.pmid: 8678143
references.citation: Headache. 2009 Nov-Dec;49(10):1414-22
references.pmid: 19804390
references.citation: Am Fam Physician. 2003 Jun 15;67(12):2517-24
references.pmid: 12825840
references.citation: Obstet Gynecol. 2003 Jul;102(1):181-92
references.pmid: 12850627
references.citation: Neurol Clin. 2012 Aug;30(3):835-66
references.pmid: 22840792
references.citation: N Engl J Med. 2000 Jan 6;342(1):29-36
references.pmid: 10620647
references.citation: Am Fam Physician. 2002 Dec 1;66(11):2123-30
references.pmid: 12484694
references.citation: J Neurol. 2003 Oct;250(10):1179-84
references.pmid: 14586598
references.citation: Thromb Res. 2012 Oct;130 Suppl 1:S19-22
references.pmid: 23026652
references.citation: Headache. 2010 Apr;50(4):563-75
references.pmid: 20132339
references.citation: J Neuroophthalmol. 2013 Mar;33(1):9-12
references.pmid: 22635167
references.citation: Cephalalgia. 2003 Apr;23(3):197-205
references.pmid: 12662187
references.citation: Radiographics. 2006 Oct;26 Suppl 1:S19-41; discussion S42-3
references.pmid: 17050515
references.citation: Ther Drug Monit. 2008 Feb;30(1):5-9
references.pmid: 18223456
references.citation: JAMA. 1989 Feb 17;261(7):1039-43
references.pmid: 2644457
references.citation: J Neurol Sci. 2007 Nov 15;262(1-2):122-30
references.pmid: 17720201
references.citation: Neth J Med. 2004 Nov;62(10):393-6
references.pmid: 15683096
references.citation: N Engl J Med. 2010 Aug 12;363(7):e10
references.pmid: 20842779
references.citation: J Headache Pain. 2012 Oct;13(7):557-65
references.pmid: 22935969
references.citation: Cleve Clin J Med. 2009 Feb;76(2):113-27
references.pmid: 19188477
references.citation: Clin Obstet Gynecol. 2013 Jun;56(2):389-96
references.pmid: 23563883
references.citation: Curr Opin Cardiol. 2000 Sep;15(5):316-21
references.pmid: 11128183
references.citation: J Stroke Cerebrovasc Dis. 2013 Nov;22(8):1252-7
references.pmid: 22902146
references.citation: Indian J Endocrinol Metab. 2011 Sep;15 Suppl 3:S188-96
references.pmid: 22029023
references.citation: J Neurol. 2000 Apr;247(4):252-8
references.pmid: 10836615
references.citation: Stroke. 2012 Aug;43(8):2115-9
references.pmid: 22821609
references.citation: Eur J Endocrinol. 2010 Mar;162(3):453-75
references.pmid: 19934270
references.citation: J Neurol. 2004 Jan;251(1):11-23
references.pmid: 14999484
references.citation: Clin Infect Dis. 2002 Aug 1;35(3):254-60
references.pmid: 12115090
references.citation: Am J Obstet Gynecol. 2007 Jan;196(1):e7-8
references.pmid: 17240214
references.citation: Nat Rev Neurol. 2009 Aug;5(8):449-56
references.pmid: 19597515
references.citation: Acad Emerg Med. 2008 Dec;15(12):1223-33
references.pmid: 18976336
references.citation: J Manipulative Physiol Ther. 2005 Oct;28(8):617-22
references.pmid: 16226631
references.citation: J Headache Pain. 2011 Aug;12(4):443-51
references.pmid: 21442333
references.citation: Headache. 2000 Oct;40(9):720-3
references.pmid: 11091289
references.citation: BMC Pregnancy Childbirth. 2012;12:122
references.pmid: 23121892
references.citation: Neurology. 2006 Nov 28;67(10):1809-12
references.pmid: 17130413
references.citation: Obstet Gynecol. 2002 Jan;99(1):159-67
references.pmid: 16175681
references.citation: BJOG. 2012 Dec;119(13):1558-63
references.pmid: 22925078