Headaches in pregnancy may indicate serious ailment
Pregnant women are suggestive of more serious condition like hypertensive disorder or preeclampsia. Matthew S. Robbins, MD, Director, inpatient services, Montefiore Headache Center, chief of neurology, Jack D. Weiler Hospital, Montefiore, and associate professor, clinical neurology, Albert Einstein College of Medicine, New York City, established that acute headache in 35% of pregnant women was a symptom of a more serious medical condition (secondary headache).
The authors in neurology reported that the main causes of secondary headaches were hypertensive disorders (51%), predominated by preeclampsia (33.8%).
There were some key differences in the symptoms of secondary headaches as compared to primary headaches (where headache is the only symptom). As expected, secondary headaches were associated with elevated blood pressure (55.1% vs 8.8%, P<0.0001), an abnormal neurological exam (34.7% vs 16.5%, P=0.0014), seizures (12.2% vs 0.0%, P=0.0015), as well as lack of headache history (36.7% vs 13.2%, P=0.0012) vs primary headaches.
Robert Atlas, MD, FACOG, chair of obstetrics and gynecology, Mercy Medical Center, Baltimore believes that many headaches patients are taken care by OB/GYNs, but the most concerning patients are referred for neurological consultations. He also sent an email to the MedPage Today suggesting it as a matter of serious concern, when an OB/GYN asks for a neurology consultation and patients are suffering from significant ailments.
The most common diagnosis was migraine with 59.3% of all diagnoses and vast majority (91.2%) of primary headache disorders. The most common neurological symptom was visual disturbance (56.4%). Out of 118 patients (87.9%) who underwent neuro-imaging, 55.9% were normal while 26.3% reported incidental findings and 17.8% had abnormal results leading to secondary headache as diagnosis.
According to Timothy Collins, MD, associate professor, Neurology, chief, headache division Duke University School of Medicine, the study's strengths was the detailed evaluation of patients by a neurologist. He also told MedPage Today that thorough evaluation including MRI imaging should be done in pregnant woman with new onset or sudden change in headache and any of the 'red flags' for secondary headache (hypertension, seizure, fever & abnormal neurologic examination).
Secondary headaches had considerably increased association with high blood pressure (OR 17.0, 95% CI 4.2 to 56.0) in multivariate regression models but also they were 5 times more prone to be linked with a lack of headache history (OR 4.9, CI 1.7 to 14.5). Patients with headache history and secondary headache were more prone to longer attack duration to differentiate this attack from past headaches (61.3% vs 38.0%, P=0.0027) compared to those with primary headache.
Primary headache was present in majority of pregnant patients (65%). Patients with primary headache were associated with psychiatric diagnoses (24.2% vs 4.1, P=0.0020), headache history (83.3% vs 63.3%, P=0.0012) and phonophobia (59.3% vs 34.7%, P=0.005) as compared to secondary headaches.
Robbins told MedPage Today that clinical practice was the inspiring factor for this study. He and his colleagues were frequently called on to emergency department/hospital to see pregnant women with severe headache, but little guidance from literature relating to triage and diagnostic workup was available. He believes that, this study for the first time enumerates the association of various risk factors for secondary headache in pregnant women and provides for the practicing neurologist and obstetrician a breakdown of diagnoses that are possible in future patients presenting with severe headache.
This retrospective chart review was conducted using data from July 2009 through June 2014. 140 pregnant women presenting to the emergency department, labor and delivery triage, or ante partum units of an urban medical center were enrolled in the study. Demographically, the women had a mean age of 29.4 years (+/- 6.4 years) and were mostly African American (39.3%) or Hispanic (36.4%). 56.4% were in their third trimester and 78.6% had headache history. The retrospective design and demographic characteristics with high percentage of African American and Hispanic women significantly influencing rates of preeclampsia were the major limitations of study.
Atlas added that the study does not account for the total number of patients who actually present with headaches and do not need neurological consultation from OB/GYNs so the actual number of patients presenting with headache throughout pregnancy is much greater.
Robbins would like to see the data validated in other populations, including the general obstetrical population rather than who just present to the hospital setting. He believes that some information is known about migraine and the risk of adverse pregnancy consequences at delivery but little is known about those presenting with severe headache during pregnancy and its influence on pregnancy outcomes like the later development of preeclampsia, preterm delivery, low birth weight and cesarean section rates.