Headache is one of the most common complaints that bring patients to see healthcare professionals, and is among the least understood and, unfortunately, least easily treated. In this exclusive Ƶ video interview, Matthew Robbins, MD, of Albert Einstein College of Medicine and Montefiore Medical Center in the Bronx, N.Y., discusses the epidemiology and treatment options for one population in whom headache disorders especially common and complex to treat: pregnant women.
A transcript of his remarks follows:
I am Dr. Matthew Robbins. I am an associate professor of neurology at Albert Einstein College of Medicine. I'm the director of the neurology service here at the Jack Weiler Hospital of Montefiore Medical Center, and here I am.
Headache disorders are, by and large, much more common in women than in men, and the population prevalence is three times as common in women than in men, and that ratio is much higher in women of childbearing age. Migraine for childbearing-age women is an important clinical problem just by the sheer scope of the epidemiology.
For women of childbearing age, it's best to identify that they have migraine before they become pregnant so they can understand what the prognosis and what the treatment options might be while they're pregnant or while they're breastfeeding after delivery.
The other issues that are important are that headache presentations in pregnant women or in postpartum women are also important to be familiar with because some could signify dangerous secondary disorders like pituitary disease, venous thrombosis, preeclampsia, especially, and other disorders. Whereas, the most common presentation of headache in pregnant women is typically migraine, and sometimes it's hard to identify just by clinical grounds what is the diagnosis at initial presentation. It requires some familiarity with what might be the more specific red flags, which could include in someone who already has a history of headache, having a more prolonged, protracted duration of a headache attack that presents in a pregnant woman. The other might be having headache in the context of having elevated blood pressure, even just one reading, and that might prompt more vigilant screening or monitoring for a condition like preeclampsia.
Headache treatment in pregnancy, particularly if it's migraine, can still be done. It's not like all medicines or therapies are off limits. Certainly, medicines that have been used in pregnant women for decades now such as acetaminophen and antiemetics like metoclopramide are quite safe and have good evidence for people with migraine in the non-pregnant population.
But other treatments might also be available. Certainly we avoid non-steroidal anti-inflammatory agents for a variety of teratogenic reason, but triptans, which are sort of the first designer medicines for treating migraine attacks traditionally had been avoided in pregnant women for fear of teratogenicity or placental insufficiency. But more recent data has shown that pregnant women exposed to sumatriptan, in particular, do not seem to have greater adverse delivery outcomes or malformation rates in babies born to such mothers than the general population. In certain circumstances, they can pick those agents to potentially be used.
In other treatments that are not sort of systemic, not oral or intravenous medications such as nerve loss with local anesthetics that are applied to the scalp or neck, or even these neuromodulation devices that, some of which are FDA approved, treat disorders like migraine could potentially be quite safe in pregnant women.
I think on the diagnostic side, whether headache is migraine or not in a pregnant or postpartum woman, and understanding what are some of these red flags that we discussed. What are the safe treatment options? What might be the prognosis of migraine in pregnant women? Because most women who have migraines, especially those who do not have aura, do much better in pregnancy than they did before they became pregnant. Although, those who do have aura, which is defined as a reversible neurologic symptom in association with a headache attack, may do worse or have their first onset of migraine during pregnancy.
Then the final thing might be that migraine is a risk factor for some adverse delivery or birth outcomes or maternal outcomes in pregnant women, and the most notable one that's been consistent across epidemiologic studies has been preeclampsia. Although migraine and preeclampsia share some symptoms such as headache, visual symptoms, migraine is actually an independent risk factor for the development of preeclampsia.