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Pregnant Patient Struggles with Recent Onset Migraines

A 31-year-old woman who is four months pregnant comes to your office complaining about recent onset headaches. These have started to occur over the past few weeks with the patient attributing them to her pregnancy.

The patient reports becoming extremely nauseous once the headaches start and often dizzy. When sitting at her desk at work, the patient noticed that staring at her computer screen made her headache worse. Sometimes she experiences ringing in her ears and bright spots while she is having these headaches.

There are often times when the patient must go home because she is unable to work due to the pain. After sleeping for a couple of hours, she experiences a reduction in her headache pain.

Does this patient meet the criteria for having a migraine? Why or why not? Which medication treatment plan would you recommend and why?

  • 2 weeks 5 days
    This case presents some challenges since the patient is pregnant which not only puts her at increased risk of ominous causes of headache but also limits testing and treatment. I agree with Drs. Schlund and Sheikh. She needs to be evaluated including a complete neurologic exam (fundoscopic exam, visual acuity, visual fields) and if this is normal, she needs imaging (MRI/MrV) with the assent of her OB. Migraines are a diagnosis of exclusion but if the work up is negative, metoclopramide and Tylenol can be used for acute treatment. Preventative therapy is quite limited in pregnancy but memantine or cyproheptadine can be considered. Low dose propranolol is probably safe. Cefaly device is another consideration for both acute and preventive therapy.
  • from Doctor Unite 3 weeks 5 days
  • from Doctor Unite 3 weeks 5 days
    As mentioned, need to rule out other ominous causes of her headache especially since she is pregnant - Cerebral vein thrombosis or CVA. I would also consider Pseudotumor Cerebri. Initial evaluation should include MRI/MRA. Since she is less than 20 wks, less likely pre-eclampsia. Her symptoms certainly could be Migraines and once other ominous causes of her headache are ruled out, I would recommend metoclopramide. Can also take acetaminophen with it PRN.
  • from Generation NP 4 weeks
    Any new onset of headaches should be fully investigated before starting on any medication. Her blood pressure needs to be checked, l would order labs, MRI and referral to a neurologist.
  • from Generation NP 4 weeks
    I agree that new onset headaches during pregnancy should be investigated. The patient should see an neurologist that specializes in migraines to make sure a safe medication is prescribed. Such medication includes low dose beta blockers. Reglan can also be helpful. Other treatments would included supportive care like rest, warm compresses and etc.
  • from Doctor Unite 4 weeks
    Yes agree she meets criteria. I’d use Reglan im first
  • from Doctor Unite 4 weeks
    The first thing I would like to comment on is the recommendation by one of the other members that the pt try Aimovig if the migraines persist. I would recommend against this as the medication is relatively new and it is just not worth the risk(think back to Thalidomide use in the 50s and 60s). As far as presumptively diagnosing this pt with migraine headaches, I agree with Huma Sheikh, that an evaluation is required first to include checking her blood pressure and looking at her fundi for papilledema. I would also ask about a family history of intracerebral aneurysms and connective tissue disorders. I would also consider ordering a MRI/MRA scan after consultation with her OB provider and a neurologist. Even a 1% chance of a particular disease process is a big risk when the wager is your life. Be careful out there and protect your patients--they're counting on you. John
  • from Doctor Unite 4 weeks
    The patient's recent onset of migraines could be attributed to hormonal changes with pregnancy. Based on her symptoms and history she seems to be suffering from migraines due to looking at the computer screen, ringing in the ears, and bright spots. Lack of quality sleep also could also cause migraines. She could try using an anti-glare screen cover for her computer. If the migraines persist, she could try an anti-CGRP such as erenumab (Aimovig).
  • 1 month
    Any new headache during pregnancy should be investigated for secondary causes. Migraine can come on during pregnancy but given that there is hypercoagulability, it is important to rule out SVT or other causes. The headache does have some migrainous feature but the bright spots need to be teased out more.