Case 8 - A 30-Year-Old with Worsening Migraine Headaches at 14 Weeks

Summary

Migraine headaches occur in 1 in 5 reproductive-aged women and are often seen in pregnancy. When treating pregnant patients for headaches, it is important to differentiate primary and secondary etiologies. Secondary etiologies may present with fever, altered mental status, and neurologic deficits and warrant immediate evaluation with head imaging using magnetic resonance or computed tomography. Migraine headaches present with prodromal symptoms followed by 4–72 hours of a unilateral, pulsating headache associated with nausea, emesis, photophobia, and/or phonophobia. Management of migraines in pregnancy relies on analgesic medications when headaches occur. Medications known to be safe in pregnancy are considered first-line, and include acetaminophen, metoclopramide, diphenhydramine, and ibuprofen (which is limited to the second trimester). A safe alternative medication is sumatriptan. Opioids and butalbital should be avoided due to the risks of medication overuse headache and neonatal withdrawal. Ergot alkaloids should never be used as they are known to be potent vasoconstrictors and cause uterine contractions. Rarely, patients require daily prophylactic treatment with a beta blocker.