Headache in Pregnancy: An Overview of Differential Diagnoses

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Research Article Open Access
Volume 2 • Issue 1 • 1000130
J Preg Child Health
ISSN: 2376-127X JPCH, an open access journal
Open Access
Review Article
Journal of Pregnancy and Child Health
Ng et al., J Preg Child Health 2015, 2:1
http://dx.doi.org/10.4172/2376-127X.1000130
Headache in Pregnancy: An Overview of Differential Diagnoses
Natasha Ng, Samantha Cox and Sachchidananda Maiti*
North Manchester General Hospital, Manchester, UK
Abstract
Headache is a common symptom in pregnancy, reported in up to 35% of women during their antenatal period.
During pregnancy, women may experience their rst episodes of headache, which could become a recurrent problem.
The purpose of this review is to recognise the classical presentation and contributory factors of primary and secondary
headaches. Primary headaches include tension type headache and migraine. Secondary headaches include
hypertension, pre-eclampsia, idiopathic intracranial hypertension, subarachnoid haemorrhage, cerebral venous
thrombosis, and reversible cerebral vasoconstriction syndrome. As we encounter headaches so frequently in patients
who are pregnant, we need to equip ourselves to recognise the ‘red ag’ signs that would alert practitioners to the need
for urgent management and differentiate it from those that are benign.
This article will cover the following topics:
• Primary Headaches
− Tension Type Headache
− Migraine
• Secondary Headaches
− Hypertension/Pre-Eclampsia
− Idiopathic Intracranial Hypertension o Subarachnoid haemorrhage
− Cerebral Venous Thrombosis
− Reversible Cerebral Vasoconstriction Syndrome
• Assessment of patients with headache
• Red Flag Signs
*Corresponding author: Sachchidananda Maiti, Obstetrics and Gynaecology, North
Manchester General Hospital, University of Manchester Medical School Manchester,
UK, Tel: 441617202235; Fax: 1617935765; E-mail: d_maiti@yahoo.co.uk
Received: November 11, 2014; Accepted: January 16, 2015; Published: January
19, 2015
Citation: Ng N, Cox S, Maiti S (2015) Headache in Pregnancy: An Overview of
Differential Diagnoses. J Preg Child Health 2: 130. doi:10.4172/2376-127X.1000130
Copyright: © 2015 Ng N, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
consequence of a predisposing medical condition. ese headaches
generally improve during pregnancy and pose no signicant risk to the
pregnancy [1,2]. e IHD includes the following conditions as primary
headaches:
− Tension Type Headaches (TTH)
− Migraine
− Cluster Headache
− Other Primary Headaches [3]
is article will only discuss TTH and Migraines as these are the
most commonly encountered primary headaches in pregnancy.
Tension type headache (TTH)
Tension headaches are extremely common and have a lifetime
prevalence of up to 88% in women [4]. TTH is thought to be secondary
Keywords: Headache; Pregnancy; Tension; Migraine
Introduction
Headache is a common presenting complaint in pregnancy. For
some women it may be their rst encounter of signicant headaches.
e majority of headaches are benign and settle with conservative
treatments, such as simple analgesia. However it is crucial to be able to
dierentiate headaches that are benign from those that are secondary
to conditions that predispose patients to a higher risk of morbidity and
mortality. Headaches may be an initial symptom of a life threatening
condition, such as Central Venous rombosis (CVT). Consequently,
headache in pregnancy can cause much anxiety, not only for the patient
but also for the attending clinicians. It is important that pregnant women
presenting with headache are thoroughly assessed and investigated in
order to rule out any serious underlying pathology.
e International Headache Society (IHD) classies headaches
as either primary or secondary. Primary headaches are benign and
have no underlying medical problem associated with them. Examples
include Tension Type Headache (TTH) and Migraines. Secondary
Headaches occur as a result of medical conditions such as hypertension,
pre-eclampsia, idiopathic intracranial hypertension, subarachnoid
haemorrhage, cerebral venous thrombosis and reversible cerebral
vasoconstriction syndrome.
We will briey describe the typical presentation and clinical features
of the dierent types of headache.
Primary headaches
Primary headaches can be considered benign and are not the

J Preg Child Health
2376-127X JPCH, an open access journal
Citation: Ng N, Cox S, Maiti S (2015) Headache in Pregnancy: An Overview of Differential Diagnoses. J Preg Child Health 2: 130. doi:10.4172/2376-
127X.1000130
Page 2 of 6
Volume 2 • Issue 1 • 1000130
to muscle contraction, however the exact mechanism is not fully
understood. TTH can be related to periods of stress [1]. It can be
further dierentiated in to frequent, infrequent, chronic and probable
TTH depending on the timing and chronicity of the episodes [3]. TTH
is the most common headache encountered in pregnancy and women
may classically present with the following features:
• Bilateral Headache
• Tight, band-like pain
• No associated aura
Patients with TTH will not have the pain worsened by physical
activity and will have no abnormal ndings on neurological examination
[1,3,4]. TTH poses no risk to the developing pregnancy, and limited
studies propose that episodes of TTH decrease during pregnancy [2].
TTH can be managed with simple over the counter analgesics, such
as paracetamol and codeine. Non-Steroidal Anti-Inammatory Agents
(NSAIDS) are contraindicated during pregnancy.
Migraine
Migraine is a common disorder characterised by a unilateral
headache that is throbbing and pulsating in nature and can be associated
with aura [3]. Migraines are three times more common in women than
in men [1] and occur with the greatest frequency in the childbearing
years [5]. Migraines will therefore aect the care of many pregnant
women. e pathogenesis of migraine, though largely uncertain, is
correlated with cerebral vasculature vasodilatation, serotonin release
and stimulation of nociceptors [1]. Migraine can be precipitated by
a single or combination of trigger factors. ese can include dietary
triggers, such as chocolate and cheese, stress, and hormonal inuences
[1,3,4]. Women who suer with migraines around the time of menarche
tend to have a reduction in migraine episodes during pregnancy.
Migraine can present for the rst time in pregnancy.
e IHCS classies migraine in to two categories, either being
associated with aura or without aura[3]. e presenting features of a
migraine headache are as follows:
• Unilateral headache
• robbing/Pulsating nature
• Moderate intensity
• Worsened by any physical activity
• Associated with either photophobia or phonophobia
• Nausea or vomiting present [1,3,4,5]
Migraines are commonly described over 4 phases, having an initial
prodromal phase, followed by aura, headache and the post-dromal
phase [4]. e prodromal phase can have an onset of hours before
the headache, and can include numerous sensory symptoms, such as
hemianopia, dysphasia, photophobia and phonophobia [1,4]. is is
followed by the classical aura, which usually occurs just before or at the
same time as the headache. It includes the visual symptoms scotoma,
fortication spectra, specks and ashes, as well as generalised sensory
symptoms such as paraesthesia. is is followed by the classic headache
described above and the post-dromal phase.
Migraine most commonly improves in pregnancy, especially
during the second and third trimesters [1,6]. Some studies have shown
that women who suer with migraines are at increased risk of pre-
eclampsia, and therefore it is of great importance to monitor their
blood pressure and obtain a urine dipstick [1,5]. Studies also report that
women who suer with migraine without aura have better symptom
control during pregnancy [7,8].
Neurological examination of a pregnant woman with a migraine
is usually equivocal. e prodromal and aura symptoms may lead to
focal neurological signs, such as reduced sensation and, in cases of
hemiplegic migraine, focal weakness. In these cases it is extremely
important that full investigations are carried out in order to rule out
other underlying causes of headache. It is very dicult in these clinical
situations to dierentiate between hemiplegic migraine and other
dierential diagnoses, such as CVT or transient ischaemic attacks [1].
Acute migraine can be managed with conservative measures, such
as analgesia, hydration and anti- emetics. Paracetamol and codeine
are most commonly used as they are deemed the least harmful during
pregnancy. NSAIDS, such as ibuprofen, are contraindicated, especially
in the third trimester, as they can cause premature closure of the patent
ductus arteriosus [8]. Serotonin receptor antagonists (Triptans), such
as Sumatriptan, are used commonly in the non-pregnant population
to treat migraines. ere is limited evidence regarding the safety of
triptans during pregnancy. ere is the most amount of evidence for
the use of Sumatriptan, which can be considered in severe migraines
non responsive to simple analgesics [5,8].
Patients suering with recurrent migraines during pregnancy should
be considered for prophylactic treatment. Simple methods include
avoiding triggers, ensuring a good sleep and nutrition pattern with
moderate exercise and relaxation [9]. Non-pharmacological methods
include biofeedbackrelaxation techniques and acupuncture. Both of
these methods have evidence to reduce migraine frequency in the non-
pregnant population and therefore could be applied to the pregnant
population [9]. Pharmacological agents employed for prophylaxis
include low dose aspirin, propranolol, tricyclic antidepressants such as
amitriptyline, and calcium channel antagonists. ese should be used
in a stepwise fashion, with aspirin being the rst line as this poses least
risk to mother and fetus [1].
Secondary headaches
Secondary headaches are headaches caused by an underlying
medical condition. ese conditions can be benign (e.g. Idiopathic
Intracranial Hypertension) or can be the rst sign of serious underlying
pathology (e.g. CVT). erefore it is important to know how to
dierentiate and investigate these headaches appropriately in order to
reduce morbidity.
Hypertension/ Pre-Eclampsia
Hypertension in pregnancy falls under the following classications
in the NICE guidelines, depending on the onset of the hypertension
and whether signicant proteinuria is present or not:
• Chronic Hypertension – hypertension present prior to
conception
• Gestational Hypertension – new onset hypertension aer 20
weeks gestation
• Pre-Eclampsia – new onset hypertension aer 20 weeks
gestation with signicant proteinuria [10]
Headache is a common presenting feature of hypertension. e
most worrying underlying conditions are uncontrolled hypertension
and Pre-Eclampsia, as complications can include eclamptic seizures
and stroke [11]. e features of a headache secondary to hypertensive

J Preg Child Health
2376-127X JPCH, an open access journal
Citation: Ng N, Cox S, Maiti S (2015) Headache in Pregnancy: An Overview of Differential Diagnoses. J Preg Child Health 2: 130. doi:10.4172/2376-
127X.1000130
Page 3 of 6
Volume 2 • Issue 1 • 1000130
disorders are as follows:
• Bilateral
• Pulsating
• Aggravated by physical activity [3,5]
Pre-eclampsia is dened as pregnancy induced hypertension (BP
>140/90 mm Hg) with associated proteinuria (>0.3g in 24 hours). In
pre-eclampsia, patients may complain of severe frontal headaches,
visual disturbances, epigastric pain most importantly sudden swelling
(oedema) of face, hands and feet [11].
Neurological examination of a patient with pre-eclampsia
underlying a headache may have brisk reexes with clonus. ere
should not be any focal neurology present. Investigation of any pregnant
woman presenting with a headache should include a blood pressure
reading and urine dip in order to rule out pre-eclampsia.
Idiopathic intracranial hypertension
Idiopathic intracranial hypertension (IIH) is a benign condition
characterised by increased pressure of the Cerebrospinal Fluid
(CSF) (>250 mm H2O at lumbar puncture) without any features of
space occupying lesion or hydrocephalus [12]. The underlying
pathophysiology is unknown, but it is known to be 8 times more
common in women than in men and in obese patients in the
childbearing years [5,12]. e headache associated with IIH has the
following features:
• Diuse constant pain
• Aggravated by coughing or straining
• Oen retro-orbital, but can be in close temporal relation to
the area of increased pressure [1,3]
Neurological examination will reveal no focal neurology, although
papilloedema is observed and occasionally unilateral or bilateral sixth
nerve palsy can be seen. e patient may complain of visual disturbances,
including visual eld defect and reduced visual acuity [1,12].
IIH is a diagnosis of exclusion and should be fully investigated to
rule out other dierential diagnoses, including space occupying lesions
and CVT [12]. A CT scan of the head will rule out any space occupying
lesions, whilst an MRI with contrast will rule out a CVT. IIH is not
a risk to the pregnancy and any decisions regarding mode of delivery
should be made based on obstetric factors only [12]. A lumbar puncture
can be performed safely in pregnancy, and examination of the CSF will
show a normal composition. Studies have shown that pregnancy does
not have any impact on the composition of the CSF, therefore if there
are abnormalities discovered they should be taken seriously [6].
Management of IIH is the same during pregnancy and in the
non-gravid patient. Lifestyle modications like weight reduction
and optimising weight control during pregnancy is rst line.
Ophthalmological review of visual elds looking specically for
progressive changes is a marker of severity. Urgent intervention is
required where visual symptoms are found. Medical management
includes appropriate use of analgesia and carbonic anhydrase inhibitor
i.e. acetazolamide [1,12]. is medication is best avoided in the rst
trimester [1]. Excessive CSF production may be an indication for
repeated lumbar puncture or more permanent measures such as
lumboperitoneal or ventriculoperitoneal shunts [12].
Subarachnoid haemorrhage
Subarachnoid Haemorrhage (SAH) following a ruptured
intracranial aneurysm is a rare but potentially serious complication of
pregnancy. Physiological changes during pregnancy can predispose to
an increased risk of SAH, particularly during the third trimester when
maternal cardiac output and circulating volume reaches its maximum.
In addition, it is also thought that increased exposure to circulating
hormones including oestrogen, progesterone and human chorionic
gonadotrophin may predispose to development or progression of
intracranial aneurysms [13].
e incidence of SAH during pregnancy and puerperium is within
the range of 3 to 10 per 100,000 pregnancies [14]. A typical presentation
would involve a sudden onset ‘thunder clap headache’ described as the
‘most severe headache’, oen of a short lived duration. Other symptoms
can include neck stiness, photosensitivity, diplopia, seizures or
uctuating consciousness. Symptoms preceding the headache involving
a third nerve palsy associated with retro-orbital pain and mydriasis
may herald an impending rupture of a posterior communicating artery
aneurysm. Neuroradiological imaging in the form of CT is the imaging
modality of choice. If the diagnosis remains in doubt, a lumbar puncture
could be performed in the absence of contraindications to investigate
for the presence of xanthochromia, which is diagnostic. Management
of ruptured intracranial aneurysms during pregnancy are largely based
on careful considerations given to maternal health at presentation,
gestational age of the pregnancy and neurosurgical opinion. Emergency
caesarean section followed by neurosurgical intervention [clipping or
coiling of aneurysm] could be indicated following a positive diagnosis.
Although SAH during pregnancy may be associated with high
morbidity and mortality, the necessity of intracranial screening for
high-risk pregnancies remain controversial [14].
Cerebral venous thrombosis
Physiological changes to the coagulation system during pregnancy
and puerperium render the maternal circulation a prothrombotic state
and therefore at an increased risk of thrombus formation and stroke.
Some of these physiological adaptations include a reduction in protein S
levels and an overall increase in levels of coagulant factors V, VIII, IX, X
and brinogen thus creating an overall shi towards a hyper-coagulable
state. is is thought to be in anticipation of the haemostatic challenges
of delivery and tends to persist during puerperium. In addition,
prolonged bed rest, instrumental delivery or caesarean section are
amongst the other well recognised factors predisposing to tendencies
towards thrombosis secondary to venous stasis and hypercoagulability
[15,16].
Among the potentially life threatening causes of secondary
headaches, Cerebral Venous rombosis (CVT) accounts for a large
proportion of the cases accounting for an incidence estimated at
11.6 per 100,000 deliveries [17]. e condition is most commonly
encountered either late in pregnancy (women in their third trimester
of their pregnancy) or postpartum, with these women being at greatest
risk. However, cases have been reported as early as 8 weeks [16]. e
clinical manifestations of obstetric CVT appear relatively similar to
CVT unrelated to pregnancy with headache being the most commonly
reported initial symptom. Lurlaro et al in their prospective multi centric
study noted several characteristic features of headache in CVT including
a tendency towards an acute/sub-acute onset, moderate to severe pain,
localized and continuous symptom [18]. Other symptoms include
focal decits, seizures and altered mental status especially drowsiness
and somnolence have also been noted. Cantu et al in their review
also reported the tendency towards a more acute course with early
stabilization observed among patients with obstetric related CVT [19].

J Preg Child Health
2376-127X JPCH, an open access journal
Citation: Ng N, Cox S, Maiti S (2015) Headache in Pregnancy: An Overview of Differential Diagnoses. J Preg Child Health 2: 130. doi:10.4172/2376-
127X.1000130
Page 4 of 6
Volume 2 • Issue 1 • 1000130
e imaging modality of choice for patients with headache
suspicious of CVT is Magnetic Resonance Imaging (MRI) with T2
weighted imaging and MR venography. However, due to lower cost and
ready availability, CT is widely used as the initial imaging modality. CT
has relatively low sensitivity however, with detection rates of only 30%
[5]. In addition, further investigations maybe necessary if underlying
thrombophilia, inammatory or vasculitic disorders were suspected.
Treatment of CVT consists of anticoagulation with low molecular
weight heparin of at least six months duration to prevent further
thrombosis. Endovascular therapy can be considered in cases of
neurological deterioration in spite of anticoagulation.
Owing to recent advancements in neuro-radiological imaging,
which has enabled both early diagnosis and management, a trend
towards lower mortality rates as well as improved outcomes have
increasingly been observed. Previous studies of various obstetric CVT
series have reported mortality rates ranging from 4-33% [16,20,21].
e long term outcome including likelihood of recurrence of CVT
during subsequent pregnancies remains unclear. However, it is known
that these patients are at a higher risk of further thrombotic events and
hence recommendations for prophylactic LMWH during pregnancy
and the puerperium [5].
Reversible cerebral vasoconstriction syndrome
Reversible Cerebral Vasoconstriction Syndrome (RCVS) is among
the other secondary headache disorders that are increasingly recognised
with signicant associations with the peurperium [22]. Other known
precipitating factors include the use of vasoconstrictive medications,
with ergot derivatives mainly implicated [23]. RCVS is a form of
post-partum angiopathy characterised by angiographic appearance of
multifocal arterial constriction and dilatation. Headache is the most
commonly reported symptom and is oen seen in association with
other symptoms, including altered mental state (confusion, agitation),
visual disturbances (blurring of vision and photophobia),seizures,
nausea and vomiting [22]. Unlike other secondary headache disorders,
the headache in RCVS can be distinguished mainly by its characteristic
diuse, sudden and severe onset occurring in multiple attacks, not
infrequently described as a ‘recurrent thunderclap headache’ [22].
Diagnosis is conrmed by demonstration of characteristic ‘string
of beads’ appearance on angiography typically with spontaneous
resolution of symptoms within 1-3 months [5]. Given the overlapping
presentations of postpartum angiopathy and various other secondary
headache disorders, relevant investigations to exclude a diagnosis
of subarachnoid haemorrhage and eclampsia also form part of the
diagnostic workup. Careful considerations of some of the accompanying
features can be useful, including BP and proteinuria, which are of
particular signicance.
At present, there are no known treatments for RCVS. Treatments
including calcium channel antagonists, magnesium sulphate and high
dose corticosteroids have been trialled with good outcomes [22,24].
Assessment of headaches in pregnancy
In most cases, pregnant women with primary headache disorders
have been diagnosed before pregnancy. However, as many as 10%
present initially or are rst diagnosed during pregnancy [25]. In
addition, obstetric complications giving rise to secondary headaches or
headache disorders presenting only during pregnancy may also occur.
A detailed account of the timeline of the headache and its relation
to the current pregnancy or any previous pregnancies should therefore
be accurately established (Box 1). Other features within the headache
history including the severity, frequency of attacks, location, character
of the pain and any associated symptoms considered as appropriate.
A high index of clinical suspicion of a serious secondary cause of
headache in women who present with certain ‘red ag’ features should
be maintained (Box 2) [26,27].
A thorough neurological examination should follow in order
to evaluate key symptomatology elicited from the history. Key
examinations used to evaluate headache in pregnancy and puerperium
include the following [5]:
• Fundoscopy for signs of raised intracranial pressure e.g.
papilloedema
• Full neurological examination: tone, power, reexes and
coordination of all four limbs
• Plantar responses
• Cranial nerve assessment
• Gait assessment
• Blood pressure, urinalysis for proteinuria and clonus
e approach to neuro-radiological imaging in pregnancy is largely
guided by desires to avoid potentially harmful foetal exposures to
BOX 1: Key features to obtain in the history when assessing headaches in pregnancy.

J Preg Child Health
2376-127X JPCH, an open access journal
Citation: Ng N, Cox S, Maiti S (2015) Headache in Pregnancy: An Overview of Differential Diagnoses. J Preg Child Health 2: 130. doi:10.4172/2376-
127X.1000130
Page 5 of 6
Volume 2 • Issue 1 • 1000130
radiation and contrast material. In clinical practice however, the choice
of imaging modality is still much guided by the suspected pathology
and availability of radiological services. During pregnancy, 50mGy is
generally taken as the cut o for accepted background cumulative dose
of ionising radiation. Foetal radiation exposure through scatter appears
to be minimal during maternal head CT, estimated at <0.005mGy. MRI
appears to be preferential to any other imaging modality involving
ionizing radiation however should be avoided in the rst trimester due
to potential hazards of hyperthermia and acoustic noise [5]. Current
recommendations are that iodinated contrast materials to be used in
pregnancy only where clinically indicated. Evidence suggests that the
iodinated contrast materials cross the placenta to produce transient
eects on the developing foetal thyroid gland and, hence, if used in
pregnancy, foetal thyroid function should be evaluated on delivery.
Gadolinium based contrast agents have an overall better safety prole
during pregnancy [28,29]. Lactating women can continue to breast feed
as concentrations of iodinated or gadolinium based contrast within
breast milk are negligible [28].
Conclusion
Headaches in pregnancy and the purperium is not an uncommon
occurrence, accounting for a considerable proportion of avoidable
morbidity and mortality. Although primary headache disorders account
for most cases, a high clinical suspicion for secondary headaches
is necessary to avoid delayed diagnosis of headaches secondary to
obstetric complications or conditions. e management of headaches
BOX 2: Red ag features suggestive of serious underlying disorder requiring further investigations.
during pregnancy appears to be relatively similar to that outside of
pregnancy. However, careful considerations have to be made including
plans for delivery, safety of medication use antenatally and when breast
feeding as to optimize management and overall outcomes of pregnancy.
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J Preg Child Health
2376-127X JPCH, an open access journal
Citation: Ng N, Cox S, Maiti S (2015) Headache in Pregnancy: An Overview of Differential Diagnoses. J Preg Child Health 2: 130. doi:10.4172/2376-
127X.1000130
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Citation: Ng N, Cox S, Maiti S (2015) Headache in Pregnancy: An Overview
of Differential Diagnoses. J Preg Child Health 2: 130. doi:10.4172/2376-
127X.1000130