Focus on primary care diagnosis and management of headache in women

Peripheral nerve blocks in the treatment of migraine in pregnancy

OBJECTIVE

To describe the use of peripheral nerve blocks in a case series of pregnant women with migraine.

METHODS

A retrospective chart review of all pregnant patients treated with peripheral nerve blocks for migraine over a 5-year period was performed. Injections targeted greater occipital, auriculotemporal, supraorbital, and supratrochlear nerves using local anesthetics.

RESULTS

Peripheral nerve blocks were performed 27 times in 13 pregnant women either in a single (n=6) or multiple (n=7) injection series. Mean patient age was 28 years and gestational age was 23.5 weeks, and all women had migraine, including 38.5% who had chronic migraine. Peripheral nerve blocks were performed for status migrainosus (51.8%) or short-term prophylaxis of frequent headache attacks (48.1%). Before peripheral nerve blocks were performed, oral medications failed for all patients and intravenous medications failed for most. In patients with status migrainosus, average pain reduction was 4.0 (±2.6 standard deviation) (P<.001) immediately postprocedure and 4.0 (±4.4 standard deviation) (P=.007) 24 hours postprocedure in comparison to preprocedure pain. For patients receiving peripheral nerve blocks for short-term prophylaxis, immediate mean pain score reduction was 3.0 (±2.1 standard deviation). No patients had any serious immediate, procedurally related adverse events, and the two patients who had no acute pain reduction ultimately developed preeclampsia and had postpartum headache resolution.

CONCLUSION

Peripheral nerve blocks for treatment-refractory migraine may be an effective therapeutic option in pregnancy.

Prevalence of and influencing factors for chronic headaches among pregnant women

OBJECTIVE

To determine the prevalence of headaches and their influencing factors among pregnant women.

METHODS

A cross-sectional study was conducted from January 3 to April 29, 2005, with 1357 women receiving routine pregnancy check-ups at the obstetric clinics of the community health institutions of Kayseri, Turkey. A structured questionnaire and the Zung Depression Scale were used to collect data.

RESULTS

Overall, 24.6% (95% confidence interval, 22.3%-26.9%) of the participants had headaches before pregnancy, whereas only 17.9% (95% confidence interval, 15.9%-20.1%) had headaches during pregnancy. Although the headache prevalence was lower during than before pregnancy, it was high among the participants aged 35 years or older, those who received help in their housework, and those who were multiparous. Moreover, the Zung depression score was significantly high among those experiencing headaches.

CONCLUSION

The significant decrease in headache prevalence observed during pregnancy may be the result of a pregnancy-specific hormonal status. However, the most significant factors influencing the frequency of headaches in the participants were related to their socioeconomic status and the severity of depression.

Pain at Midlife

Although menopause is a normal developmental milestone through which all women pass, the transition has been long associated with chronic pain conditions that may be more accurately viewed as secondary to aging. Clinicians need to understand management of pain problems women may experience. This article examines pain syndromes including headache, back pain, osteoarthritis, pelvic pain, vulvo-vaginal pain, and burning mouth syndrome.

Recognition and treatment of menstrual migraine

BACKGROUND

Menstrual migraine is a chronic disorder affecting approximately 12.6 million women in the United States. In spite of its widespread prevalence, menstrual migraine often goes undiagnosed.

REVIEW SUMMARY

Characteristics of menstrual migraine, which include functional disability, increased headache severity, and lack of aura, are often overlooked, and therefore menstrual migraine is often underdiagnosed. Use of a 3-month diary to record migraine patterns can reveal the predictable patterns associated with menstrual migraine, and a diary is demonstrated to be a useful tool in diagnosis. Optimal treatment of menstrual migraine takes advantage of the predictability of the disorder. Treatment alternatives for menstrual migraine include acute therapy and short- or long-term preventive therapies. Acute therapy is given shortly after the migraine begins. Short-term preventive therapies are effective when administered during the time that menstrual migraine is most likely to occur; the treatment window is typically 2 days prior up to 3 days after the onset of menstruation. Providing triptans, nonsteroidal anti-inflammatory drugs, or estrogen supplements (gel or patches) during this window has been demonstrated to provide effective protection during the days when patients are at greatest risk for menstrual migraine. Alternatively, long-term preventive therapy may be required for recurrent headaches in patients with concomitant medical conditions for whom migraine therapy could serve a dual purpose.

CONCLUSION

By recognizing the patterns associated with menstrual migraine, prompt, acute, or preventive therapy can be used to effectively manage the disorder and reduce its related disability.

[Difficult decisions: headache treatment in pregnancy and childhood]

In pregnancy and in childhood, headache and migraine are challenging therapeutic problems.However, this review aims to give treatment recommendations for drug and non-drug therapy in both patient groups which are based on scientific evidence. Pregnant women often lose their migraine attacks which reappear during lactation. During pregnancy acute headache can be treated with paracetamol, in the middle trimenon also ASA and ibuprofen are allowed. Triptans for the acute treatment of migraine are contraindicated. As prophylactic agents, only metoprolol, fluoxetine, and magnesium are possible. In childhood, drug of first choice for acute headache treatment is ibuprofen. Migraine can also be treated by sumatriptan nasal spray. In migraine prophylaxis, flunarizine is drug of first choice, no prophylactic drugs are evaluated for tension-type headache in childhood. The problems of specific contraindications and of the off-label use of drugs in this particular life periods are discussed.

Neurological disorders in pregnancy

PURPOSE OF REVIEW

Neurological disorders are common in women of childbearing age and can lead to maternal death, as evident from previous reports of the Confidential Enquiry into Maternal Deaths in England and Wales. In the last report (1997-1999) alone, there were 34 deaths indirectly caused by neurological disorders.

RECENT FINDINGS

With the new developments in drugs, investigations and research, clinicians are now more able than ever before to diagnose and treat some disorders. A recent example is the French Study Group on Stroke in Pregnancy.

SUMMARY

This paper reviews the current concepts and outlines appropriate management of conditions such as epilepsy, headache, benign intracranial hypertension, myasthenia gravis, multiple sclerosis, Bell's palsy and cerebrovascular disorders.

Headache during pregnancy

Headache in pregnancy is a common problem but diagnosis and management can be challenging. Most headaches in pregnant women are either migraine or tension types and can be easily treated. Rarely, the headache in a pregnant patient signals a life-threatening condition. Obstetricians should be able to effectively manage the common causes of headache as well as recognize the warning signs of potentially serious conditions. Diagnosis and management should be systematic yet individualized.

Menstrual cycle effects on common medical conditions

Menstrual cycle-related exacerbation of common medical conditions such as migraine, epilepsy, asthma, irritable bowel syndrome, and diabetes, is a well-recognized phenomenon. Accurate documentation of symptoms on a menstrual calendar allows identification of women with cyclic alterations in disease activity.