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12 - Approach to Pregnant or Lactating Patients with Headache in the Emergency Department

Published online by Cambridge University Press:  09 October 2017

By
Sylvia Lucas  and
Esther Rawner
Edited by
Serena L. Orr ,
Benjamin W. Friedman  and
David W. Dodick
Serena L. Orr
Affiliation:
Children’s Hospital of Eastern Ontario, Ottawa
Benjamin W. Friedman
Affiliation:
Albert Einstein College of Medicine, New York
David W. Dodick
Affiliation:
Mayo Clinic, Phoenix, AZ
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Summary

Abstract

Most pregnant women with migraine improve during pregnancy, though migraine can resume following delivery and during breastfeeding. Since many women limit their exposure to drugs during pregnancy or breastfeeding, a migraine may be undertreated, become severe, refractory, and result in the need for an emergency department (ED) visit during this period. As with non-pregnant women, early management requires differentiation between primary and secondary headache, and though most headaches evaluated in the ED are migraines, some patients will need imaging or specialty consultation for this determination. Drug safety during pregnancy and lactation will limit the use of some drugs used in the treatment of migraine. Medications for acute treatment of refractory migraine in pregnant or lactating women are discussed and include dopamine antagonists, nonsteroidal anti-inflammatory medications, magnesium, opioids, triptans, and corticosteroids. Recommendations for medication use are made on the basis of risk of the drug to a pregnant woman or nursing infant and evidence for efficacy in the ED population.

Type
Chapter
Information
Emergency Headache
Diagnosis and Management
 , pp. 125 - 140
Publisher: Cambridge University Press
Print publication year: 2017

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References

1.Lipton, RB, Bigal, ME. The epidemiology of migraine. Am J Med. 2005;118(Suppl. 1):3S–10S.Google Scholar
2.Nappi, RE, Albani, F, Sances, G, et al. Headaches during pregnancy. Curr Pain Headache Rep. 2011;15:289–94.Google Scholar
3.Hoshiyama, E, Tatsumoto, M, Iwanami, H, et al. Postpartum migraines: a long-term prospective study. Intern Med. 2012;51:3119–23.Google Scholar
4.Ertresvag, JM, Swart, JA, Helde, G, et al. Headache and transient neurological symptoms during pregnancy, a prospective cohort. Acta Neurol Scand. 2005;111:233–7.Google Scholar
5.Melhado, EM, Maciel, JA, Guerreiro, CM. Headache during gestation: evaluation of 1101 women. Can J Neurol Sci. 2007 ;34:187–92.Google ScholarPubMed
6.Fiesseler, FW, Riggs, RL, Shih, R, Richman, PB. Do patients with recurrent headaches attempt abortive therapy before their emergency department visit? J Emerg Med. 2007;32:245–8.Google Scholar
7.Klapper, JA, Stanton, JS. Current emergency treatment of severe migraine headaches. Headache. 1993;33:560–2.Google Scholar
8.Marcus, D. Managing headache during pregnancy and lactation. Expert Rev Neurotherapeutics. 2008;8:385–95.CrossRefGoogle ScholarPubMed
9.Treadwell, SD, Thanvi, B, Robinson, TG. Stroke in pregnancy and the puerperium. Postgrad Med J. 2008;84:238–45.CrossRefGoogle ScholarPubMed
10.Heit, J, Kobbervig, C, James, A, et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism during pregnancy or the puerperium: a 30-year population-based study. Ann Int Med. 2005;143:697–706.CrossRefGoogle ScholarPubMed
11.James, AH, Bushnell, CD, Jamison, MG, Meyers, ER. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol. 2005;106:506–16.Google Scholar
12.Report of the national high blood pressure education program working group on high blood pressure in pregnancy. Am J Obstet Gynecol. 2000;183:S1–S22.Google Scholar
13.Adeney, KL, Williams, MA. Migraine headaches and preeclampsia: an epidemiologic review. Headache. 2006;46:794–803.Google Scholar
14.Bushnell, CD, Jamison, M, James, AH. Migraines during pregnancy linked to stroke and vascular disease in a US population based case control study. BMJ. 2009;10:338.Google Scholar
15.Facchinetti, F, Allais, G, Nappi, RE, et al. Migraine is a risk factor of hypertensive disorders in pregnancy: a prospective cohort study. Cephalalgia. 2009;29:286–92.Google Scholar
16.Williams, MA, Peterlin, BL, Gelaye, B, et al. Trimester-specific blood pressure levels and hypertensive disorders among pregnant migraineurs. Headache. 2011;51:1468–82.Google Scholar
17.Marcoux, S, Berube, S, Brissan, J, Fabia, J. History of migraine and risk of pregnancy-induced hypertension. Epidemiology. 1992;3:53–6.CrossRefGoogle ScholarPubMed
18.Adeney, KL, Williams, MA, Miller, RS, et al. Risk of pre-eclampsia in relation to maternal history of migraine headaches. J Matern Fetal Neonatal Med. 2005;18:167–72.Google Scholar
19.American College of Obstetricians and Gynecologists. Chronic hypertension in pregnancy: ACOG Practice Bulletin no.125. Obstet Gynecol. 2012;119:396–407.CrossRefGoogle Scholar
20.Deak, TM, Moskovitz, JB. Hypertension and pregnancy. Emerg Med Clin North Am. 2012;30:903–17.CrossRefGoogle ScholarPubMed
21.Robbins, MS, Farmakidis, C, Dayal, AK, Lipton, RB. Acute headache diagnosis in pregnant women: a hospital-based study. Neurology. 2015;85:1024–30.Google Scholar
22.Ramchandren, S, Cross, BJ, Liebeskind, DS. Emergent headaches during pregnancy: correlation between neurologic examination and neuroimaging. Am J Neuroradiol. 2007;28:1085–7.CrossRefGoogle ScholarPubMed
23.ACR-SPR practice parameter for imaging pregnant or potentially pregnant adolescents and women with ionizing radiation. Resolution 39, amended 2014.Google Scholar
24.The American College of Obstetricians and Gynecologists. The American College of Obstetricians and Gynecologists women’s health care physicians guidelines for diagnostic imaging during pregnancy and lactation; no. 656, February 2016.Google Scholar
25.Ephross, SA, Sinclair, SM. Final results from the 16-year sumatriptan, naratriptan, and Treximet pregnancy registry. Headache. 2014;54:1158–72.Google Scholar
26.Nezvalova-Henriksen, K, Spigset, O, Nordeng, H. Triptan exposure during pregnancy and the risk of major congenital malformations and adverse pregnancy outcomes: results from the Norwegian mother and child cohort study. Headache. 2010;50:563–75.Google Scholar
27.Balbin, JEB, Nerenberg, R, Baratloo, A, Friedman, BW. Intravenous fluids for migraine: a post hoc analysis of clinical trial data. Am J Emerg Med. 2016;34(4):713–16.Google Scholar
28.Rozen, TD. Emergency department and inpatient management of status migrainosus and intractable headache. Continuum. 2015;21:1004–17.Google Scholar
29.FDA. Pregnancy categories for prescription drugs. FDA Drug Bulletin. 1982;12:24–5.Google Scholar
30.Koren, G, Pastuszak, A, Ho, S. Drugs in pregnancy. N Engl J Med. 1998;338:1128–37.Google Scholar
31.Kelley, NE, Tepper, DE. Rescue therapy for acute migraine: Part 3. Opioids, NSAIDs, steroids, and post-discharge medications. Headache. 2012;52:467–82.Google Scholar
32.Anderson, G. Using pharmacokinetics to predict effects of pregnancy and maternal–infant transfer of drug during lactation. Expert Opin Drug Metab Toxicol. 2006;2:947–60.CrossRefGoogle ScholarPubMed
33.Peroutka, SJ, Snyder, SH. Relationship of neuroleptic drug effects at brain dopamine, serotonin, adrenergic and histamine receptors to clinical potency. Am J Psychiatry. 1980;137:1518–22.Google ScholarPubMed
34.Parlak, I, Atilla, R, Cicek, M, et al. Rate of metoclopramide infusion affects the severity and incidence of akathisia. Emerg Med J. 2005;22:621–4.Google Scholar
35.Wijemanne, S, Jankovic, J, Evans, RW. Movement disorders from the use of metoclopramide and other antiemetics in the treatment of migraine. Headache. 2016;56:153–61.Google Scholar
36.Cete, Y, Dora, B, Ertan, C, Ozdemir, C, Oktay, C. A randomized prospective placebo-controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the emergency department. Cephalalgia. 2005;25:199–204.Google Scholar
37.Friedman, BW, Bender, B, Davitt, M, et al. A randomized trial of diphenhydramine as prophylaxis against metoclopramide-induced akathisia in nauseated emergency department patients. Ann Emerg Med. 2009;53:379–85.CrossRefGoogle ScholarPubMed
38.Momma, K, Hagiwara, H, Konishi, T. Constriction of fetal ductus arteriosus by non-steroidal anti-inflammatory drugs: study of additional 34 drugs. Prostaglandins. 1984;28:527–36.Google Scholar
39.Daniel, S, Koren, G, Lunenfeld, E, et al. Fetal exposure of nonsteroidal anti-inflammatory drugs and spontaneous abortions. CMAJ. 2014;186:E177–82.Google Scholar
40.Amundsen, S, Nordeng, H, Nezalova-Henriksen, K, Stovner, LJ, Spigset, O. Pharmacological treatment of migraine during pregnancy and breastfeeding. Nat RevNeurol. 2015;11:209–19.Google Scholar
41.Riaz, M, Porat, R, Brodsky, NL, Hurt, H. The effects of maternal magnesium sulfate treatment on newborns: a prospective controlled study. J Perinatol. 1998;18:449–54.Google Scholar
42.Langer-Gould, AM, Anderson, WE, Armstrong, MJ et al. The American Academy of Neurology’s top five choosing wisely recommendations. Neurology. 2013;81(11);1004–11.Google Scholar
43.Cooper, J, Jauniaux, E, Gulbis, B, Quick, D, Bromley, L. Placental transfer of fentanyl in early human pregnancy and its detection in fetal brain. Br J Anaesth. 1999;82:929–31.CrossRefGoogle ScholarPubMed
44.Soldin, OP, Dahlin, J, O’Mara, DM. Triptans in pregnancy. Ther Drug Monit. 2008;30:5–9.Google Scholar
45.Evans, EW, Lorbe, KC. Use of 5-HT agonists in pregnancy. Ann Pharmacother. 2008;42:543–9.Google Scholar
46.Loder, E. Safety of sumatriptan in pregnancy: a review of the literature so far. CNS Drugs. 2003;17:1–7.Google Scholar
47.O’Quinn, S, Ephross, SA, Williams, V, et al. Pregnancy and perinatal outcomes in migraineurs using sumatriptan: a prospective study. Arch Gynecol Obstet. 1999;263:7–12.Google Scholar
48.Shuhaiber, S, Pastuszak, A, Schick, B et al. Pregnancy outcome following first trimester exposure to sumatriptan. Neurology. 1998;51:581–3.Google Scholar
49.Schenker, S, Yang, Y, Perez, A, et al. Sumatriptan (Imitrex) transport by the human placenta. Proc Soc Exp Biol Med. 1995;210:213–20.Google Scholar
50.Guputa, S, Hanff, LM, Visser, W, et al. Functional reactivity of 5-HT receptors in human umbilical cord and maternal subcutaneous fat arteries after normotensive or pre-eclamptic pregnancy. J Hypertens. 2006;24:1345–53.Google Scholar
51.Innes, GD, Macphail, I, Dillon, EC, Metcalfe, C, Gao, M. Dexamethasone prevents relapse after emergency department treatment of acute migraine: a randomized clinical trial. CJEM. 1999;1:26–33.Google Scholar
52.Colman, I, Freidman, BW, Brown, MD, et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomized controlled trials for preventing recurrence. BMJ. 2008;336:1359–61.CrossRefGoogle ScholarPubMed
53.Orr, SL, Aubé, M, Becker, WJ, et al. Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia. 2015;35:271–84.CrossRefGoogle ScholarPubMed
54.Begg, EJ, Duffull, SB, Hackett, LP, et al. Studying drugs in human milk: time to unify the approach. J Hum Lact. 2002;18:323–32.Google Scholar
55.Larsen, LA, Ito, S, Koren, G. Prediction of milk/plasma concentration ratio of drugs. Ann Pharmacother. 2003;37:1299–300.Google Scholar
56.Atkinson, HC, Begg, EJ. Prediction of drug distribution into human milk from physicochemical characteristics. Clin Pharmacokinet. 1990;18:151–67.Google Scholar
57.Riant, P, Urien, S, Albengres, E, et al. High plasma protein binding as a parameter in the selection of betablockers for lactating women. Biochem Pharmacol. 1986;35:4579–81.Google Scholar
58.American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001 ;108:776–89.Google Scholar
59.http://aappolicy.aappublications.org/cgi/reprint/pediatrics.Google Scholar
60.Hale, TW. Medications and Mothers’ Milk. Amarillo, TX: Hale Publishing; 2008.Google Scholar
61.http://toxnet.nlm.nih.gov/cgi-bin.Google Scholar
62.Hutchinson, S, Marmura, MJ, Calhoun, A, et al. Use of common migraine treatments in breast-feeding women: a summary of recommendations. Headache. 2013;53:1–14.CrossRefGoogle ScholarPubMed
63.Kauppila, A, Arvela, P, Koivisto, M, et al. Metoclopramide and breast feeding: transfer into milk and the newborn. Eur J Clin Pharmacol. 1983;25:819–23.Google Scholar
64.Wischnik, A, Manth, SM, Lloyd, J, Bullingham, R, Thompson, JS. The excretion of ketorolac tromethamine into breastmilk after multiple oral dosing. Eur J Clin Pharmacol. 1989;36:521–4.Google Scholar
65.Cruikshank, DP, Varner, MW, Pitkin, RM. Breast milk magnesium and calcium concentrations following magnesium sulfate treatment. Am J Obstet Gynecol. 1982;143:685–8.Google Scholar
66.Wojnar-Horton, RE, Hackett, LP, Yapp, P, et al. Distribution and excretion of sumatriptan in human milk. Br J Clin Pharmacol. 1996;41:217–21.CrossRefGoogle ScholarPubMed
67.Trainor, A, Milner, J. Pain treatment and relief among patients with primary headache subtypes in the ED. Am J Emerg Med. 2008;26:1029–34.Google Scholar
68.Broussard, CS, Rasmussen, SA, Reefhuis, J, et al. Maternal treatment with opioid analgesics and risk for birth defects. Am J Obstet Gynecol. 2011;204:314.e1–11.Google Scholar
69.Einarson, A, Maltepe, C, Narioz, Y, et al. The safety of ondansetron for nausea and vomiting of pregnancy: a prospective comparative study. BJOG. 2004;111:940–3.CrossRefGoogle ScholarPubMed

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