Headache during pregnancy can be both primary and secondary, and in the last case can be a symptom of a life-threatening condition. The most common secondary headaches are stroke, cerebral venous thrombosis, subarachnoid hemorrhage, pituitary tumor, choriocarcinoma, eclampsia, preeclampsia, idiopathic intracranial hypertension, and reversible cerebral vasoconstriction syndrome. Migraine is a risk factor for pregnancy complications, particularly vascular events. (Negro et al, 2017)
Pregnancy increases risk for many causes of headache, including pathologic vascular processes. Migraine is the most common cause of headache during pregnancy. Headache associated with neurologic signs or symptoms or that is progressive and refractory to treatment; acute in onset; and severe, postural, or different from typical headaches should be evaluated. (Burch, 2019)
It is well established that there is a strong link between migraine headache and sex hormones, specifically estrogen, which influences the severity of migraines during the menstrual cycle, pregnancy, and menopause. (Sader & Rayhill, 2018)
The majority of women suffering from migraine without aura report improvement of their migraine attacks during pregnancy. Migraine attacks with aura can also improve during pregnancy, but more often remain the same or worsen. Anovulation caused by lactation is generally associated with a decrease in migraine attacks in breastfeeding women. (van Casteren et al, 2020)
For women with history of headache, the use of effective non-pharmacological options should be maximized, and the smallest number of the safest medicines at the lowest effective doses should be used while preparing for pregnancy and during pregnancy. (Ovadia, 2021)
Negro A, Delaruelle Z, Ivanova TA, Khan S, Ornello R, Raffaelli B, Terrin A, Reuter U, Mitsikostas DD; European Headache Federation School of Advanced Studies (EHF-SAS). Headache and pregnancy: a systematic review. J Headache Pain. 2017 Oct 19;18(1):106. doi: 10.1186/s10194-017-0816-0. PMID: 29052046; PMCID: PMC5648730.
Burch R. Headache in Pregnancy and the Puerperium. Neurol Clin. 2019 Feb;37(1):31-51. doi: 10.1016/j.ncl.2018.09.004. PMID: 30470274.
Sader E, Rayhill M. Headache in Pregnancy, the Puerperium, and menopause. Semin Neurol. 2018 Dec;38(6):627-633. doi: 10.1055/s-0038-1673681. Epub 2018 Dec 6. PMID: 30522137.
van Casteren DS, van den Brink AM, Terwindt GM. Migraine and other headache disorders in pregnancy. Handb Clin Neurol. 2020;172:187-199. doi: 10.1016/B978-0-444-64240-0.00011-8. PMID: 32768088.
Ovadia C. Prescribing for pregnancy: managing chronic headache and migraine. Drug Ther Bull. 2021 Oct;59(10):152-156. doi: 10.1136/dtb.2021.000031. Epub 2021 Aug 19. PMID: 34413163.