Ep 156: Headaches in Pregnancy

In this episode we’re talking about headaches in pregnancy. Headaches are common in general and also in pregnancy so I thought I’d tackle this topic. We will be focusing on primary headache syndromes today. A “primary headache” is when the headache itself is the disorder, whereas a “secondary headache” refers to one that is a symptom of an underlying issue. I do go into when it’s time to take a headache seriously and talk to your doctor.

Primary headaches can be pre-existing (i.e., they began before pregnancy) or can occur for the first time during pregnancy, postpartum, or breastfeeding. Depending on what kind of headaches you suffer from, pregnancy may make the condition more or less severe. Both headache treatments and the headaches themselves can have an effect on your pregnancy so it’s important to learn about your options and make informed decisions.

In this Episode, You’ll Learn About:

How common are headaches
What are the different types of primary headaches
What are the characteristics of the most common primary headaches
How headaches can affect pregnancy outcomes
What are some medication and non-medication treatments
What are some preventative measures you can take
What medications are safe to use while breastfeeding
How to tell when a headache might be a sign of a more serious problem

Links Mentioned in the Episode

Make a Birth Plan the RIGHT Way
The Birth Preparation Course
Follow me on Instagram - I'm doing live Office Hours and posting helpful daily content!
Take a quick, fun labor pain quiz
Join my email list here!

Keywords

cluster headache, headache, migraine, pain management, tension headache

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Transcript

All About Pregnancy & Birth Podcast Transcript

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Ep 156: Headaches in Pregnancy

Nicole: In this episode, you are going to learn about headaches in pregnancy. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Well, hello. Hello. Welcome to another episode of the podcast. This is episode number 156. I am so glad that you are here with me today. I'm recording this episode after getting over a bit of a respiratory virus that kept me down for like almost a week. And hopefully I don't sound too stuffy or anything like that. So forgive me if I do, I definitely feel a lot better. It was not COVID so I'm glad for that, but it just took longer to get over than I wanted to, but I'm glad to be back on the microphone and talking about headaches and pregnancy in this episode. So headaches are common in general, and they're also common in pregnancy. So definitely wanted to tackle this topic today. And the focus of the episode is on what's called primary headache syndromes. Primary headaches are one where the headache itself is the problem.

Nicole: A secondary headache syndrome is when the headache is caused by something else. I'm gonna say a word about that in a second, but in this episode, I'm focusing primarily on primary headaches and the different types of primary headaches that we're gonna talk about are migraine headaches, tension type headaches, and cluster headaches. And you're gonna learn what the typical course of those headaches is during pregnancy spoiler alert overall, they often get better during pregnancy also how headaches can actually affect pregnancy outcomes. Meaning if you have headaches during pregnancy, does it impact your pregnancy outcomes? Potentially the answer is yes. And then of course, we'll talk about some treatment options. I'll also talk a bit about postpartum headaches and you will learn some things that warrant prompt evaluation when you do have a headache. Now, as I said, I'm not talking about secondary headaches. In this episode, in this episode, secondary headaches are headaches that are, that are called by an underlying disorder.

Nicole: The most common one is preeclampsia among pregnant folks who don't have a history of headaches and they have a new headache or a worsening headache, uh, about one third will have preeclampsia. So if you are greater than 20 weeks and you have a new headache or, or it's worse than your typical headaches, then you definitely need to be promptly evaluated for preeclampsia. And that's pretty easy. I'm not gonna go into all of the diagnostic criteria for preeclampsia, but the simple first place to start is to check your blood pressure. Preeclampsia involves high blood pressure in pregnancy. So if your blood pressure is normal, you likely don't have preeclampsia, but for sure, if you're greater than 20 weeks and have a, a headache, you do wanna get evaluated for preeclampsia. But in this episode, we're gonna talk about those primary headaches, the migraines, tension type, and cluster headaches.

Nicole: Now, before we get into the episode, let me say a quick word about a really important topic, and that is childbirth education. It is so important that you take the time to invest in yourself and your pregnancy through a structured childbirth education program. Childbirth education is really important to help you advocate for yourself during your pregnancy and birth, help you to understand what's going on in your body, just feel more prepared, feel safer, um, have less fear during your pregnancy and birth. And although I don't have any evidence to support this like scientific studies or things, I also think that child birth education can be important to help reduce negative outcomes in pregnancy, whether that's maternal mortality, maternal morbidity, or problems happen, but they are what call, what are called near misses, just being empowered with education and information, and being able to advocate for yourself is so crucial.

Nicole: And yes, the podcast for sure is a part of that, but really a structured program like childbirth education is key as well. And of course I have an option that I would love to have you in the Birth Preparation Course. It's my online childbirth education course that as I say, gets you calm, confident, and empowered to have that beautiful pregnancy and birth experience that you deserve. And the great things about the course that is online, you can do it on your own time and on your own pace. You can do it with your partner. You get lifetime access to it. It's incredibly affordable for everything that comes inside of the course, but, um, what's really most important to me is that you do something. There are other options out there. So do your research and check it out. But I would love to have you inside the Birth Preparation Course, um, many folks, so many folks found it helpful.

Nicole: We've had nearly 1500 mamas go through it so far. So check out all the details of the Birth Preparation Course at drnicolerankins.com/enroll. I would love to see you there, but the important thing is don't skip childbirth education. It's super important. All right, so let's get into the episode about headaches. So as I said, headaches are really common for females in their childbearing years in one study, about 60% of females under the age of 40 reported, experiencing a headache within that previous year. So really, really common. And it's also common in pregnancy. And as I said, we're talking about primary headaches, which are conditions where the headache itself is the disorder, not secondary headaches that can be caused by preeclampsia, stroke or blood clot. Those things are not very common, but they do happen. Now primary headaches can be what's called preexisting, meaning that they started before pregnancy.

Nicole: And that's actually the case for most folks. Most folks who have trouble with headaches during pregnancy had trouble with headaches before pregnancy. So that's, that's what happens in most of the circumstances, but it is possible for people to have headaches for the, the first time during pregnancy, during the postpartum period and while breastfeeding. Okay. Now the three major types of primary headaches that we're gonna talk about are migraine headaches, tension headaches, and cluster headaches. So let's start off with migraine headaches. So migraines are the most common, most frequent type of both preexisting headaches and pregnancy onset headaches, for sure they account for about 90% of primary headaches in pregnant women. And in general, migraines are pretty common. The lifetime prevalence of migraines among pregnant women is about 30%. So roughly 30% of pregnant women will have trouble with migraines. About 2% of those will develop their first migraine during pregnancy.

Nicole: Usually that is in the first trimester. So some of the characteristics of migraine headaches 60 to 70% of cases, they tend to be unilateral, meaning it's on one side of the head in one spot and the remaining 30%, it can either be what's called by frontal, which is in both sides of the head, but mostly in the front or global where it's like your whole head is hurting. But most of the time migraines tend to be in one spot. They typically have a gradual onset where they slowly, slowly increase in intensity and they can be pretty severe in intensity actually. So the intensity just kind of creeps up, creeps up, creeps up, creeps up. Some people often describe them as pulsating in nature. Unlike other headaches, they tend to be aggravated by sort your routine physical activities. So migraines can really like sit you down.

Nicole: Like you have to lay down, rest in a dark quiet room because even routine physical activities can make that headache worse. They last anywhere from four to 72 hours and can be accompanied by things like nausea, vomiting, photophobia, meaning you don't wanna see light, phonophobia where you don't want to hear sound. Some folks may have, what's called an aura where you see things that happen before the headaches. Usually it's visual, but sometimes it can be, um, speech or, or, or, um, things you hear as well. But typically it's a visual aura that you may have before a headache. And some of the things that can trigger a migraine are of course, stress, weather changes can do it. A lot of nitrates in your diet can do it. Um, if you have sleep disturbances that can also trigger migraines as well. Now, the good news is that for most pregnant folks, um, 60 to 70% of people who have a history of migraines, uh, will report an improvement in migraines over the course of their pregnancy. And that is because migraines are influenced by fluctuations in estrogen levels. And those things tend to settle down during pregnancy. So the vast majority of folks who have a history of migraines will experience improvement during pregnancy. So that's great. Unfortunately, however, about 5% will describe that they are worse and then the remainder report, no change in their migraines at all.

Nicole: Those who are most likely to have an improvement in their migraines during pregnancy are those who have a menstrual migraine, meaning the migraine is worse during their menstrual cycle. Those who have a migraine without an aura, and those who experience improvement in their headaches in the first trimester. So if you experience improvement in the first trimester, that's likely to stay during the rest of your pregnancy. If you don't, then it's not likely to improve. And what we mean by improvement, it doesn't mean that you're necessarily gonna have no headaches, but you could have less severe attacks. They can be less frequent or they can last shorter. So they may not necessarily go away, but they may not be as bad during pregnancy. All right. So what about recurrence? The most common time if the, the migraines are gonna come back is gonna be in the postpartum period and patients who have what's called a menstrual migraine are gonna be most likely to experience a postpartum migraine as well. And that again is related to those fluctuations in estrogen. And if you breastfeed, you're less likely to experience a migraine postpartum. And that is thought to be to a more stable level of estrogen in women who are breastfeeding is kind of a protective effect against migraines.

Nicole: So let's talk the outcomes of pregnancy from women who do have migraines. Okay. And this is a little bit of a tricky one because you can't necessarily do anything to alter your risk. You know, that risk is going to be present, whether migraines are treated or untreated, but if you have some issues or concerns that pop up during pregnancy, this may help to give you an understanding or a reason why it happened or something that we know is associated with it, or it can give you some things to be on the lookout for. So let's talk about some of the outcomes related to migraines in pregnancy. So again, whether your migraines are treated or untreated, there is an association with an increased risk of hypertensive disorders of pregnancy. So that would be like gestational hypertension or preeclampsia. And that number is actually pretty, pretty, um, high in terms of the increased risk in one study of, um, over 23,000 pregnant patients, migraine was associated with a 50% increase in the prevalence for hypertensive disorders of pregnancy.

Nicole: So that is pretty high. Now that doesn't mean that you're going to get it, or that it's likely that you're going to get it. It just means that there's an increased chance that you will get it compared to people who don't have migraine headaches. Again, I don't wanna scare you just kind of making you aware of things that are out there. There was also a little bit of an increased risk in this one study in miscarriage, preterm birth and low birth weight. There was no increase in growth restriction or any sort of congenital anomalies observed, but there was that tiny increase risk, like I said, in miscarriage, preterm birth and low birth weight, and a pretty significant risk for hypertensive disorders in pregnancy.

Nicole: Now it is important to note that in this particular study, they did all also see that people who had migraines did have before pregnancy higher levels of hypertension, depression, and asthma. So those are things that may have been associated with some of the outcomes during pregnancy. So you do have to be careful about that. Um, so again, don't wanna stress you out. Don't wanna be like, oh my God, I have migraines. I'm gonna get high blood pressure. Just want to make you aware of things so you can be prepared because again, always knowledge is power. All right. So what about some of your treatment options for migraines?

Nicole: So let me step back for a minute and talk about some of the, the general treatment principles of headache in general, regardless of what the headache is. We definitely want to treat people's headaches in pregnancy because you want to be more comfortable during pregnancy. So that's a really important feature. I say that to say that you don't have to suffer, okay, you don't have to just suck it up and take it just because you're pregnant and you're trying to reduce or avoid, um, exposure to medications. Not that that's not important or that I don't understand that I totally get it, but please know that you don't have to suffer with your headaches during pregnancy, just because you're pregnant. Now with that, I do wanna be clear that there are, there actually aren't any large clinical trials or randomized studies looking at headache therapy in pregnancy.

Nicole: So we're basing all of our recommendations on looking back and seeing what has happened when people were treated. And we're basing that on our best guess also of medications and how they impact pregnancy. So do know that we don't have a lot of large trials, but we do have a lot of experience and a lot of data looking back in order to guide our recommendations and treatment. So of course, we're going to avoid anything that we know is potentially harmful during pregnancy. So we, we, and I'm gonna talk about a couple of drugs that we know are harmful during pregnancy that you cannot use at all. And then after that, we really follow treatment recommendations that are very similar for non-pregnant women okay. And we just choose the medication that has the best safety profile for the baby limit. The number of medications that we use limit the number of doses to the minimum amount needed to control the symptoms.

Nicole: So you feel better. Okay. So we start with like the least riskiest thing, take it as for the least amount of time possible in order to control symptoms. But we do go up from there if we need to, because again, it's important for you to feel well, keep in mind that there is going to be probably some, an error, all right. And figuring out what works it's typically not. Or it may not be just like a, here's a one pill. You take it, you try it. And the headache's gone. It may require some time in order to figure out a regimen that really works best for you. Okay. So keep that in mind. All right. So let's get into some of the specific treatments. One of the things that I don't think we emphasize or enough, or talk about enough or give enough, like try to, is non-medication treatments.

Nicole: Okay. So you can do things like heat ice, um, like a, a warm washcloth or a cold washcloth on your head. Massage can also help, rest can help. Of course, avoiding triggers can help like maintaining a regular meal schedule, what you eat, a reg a regular sleep pattern can also help. Also things like biofeedback being trained in biofeedback can help, relaxation training as well as cognitive behavioral therapy or all proven strategies that can help reduce headaches. Of course, they do take a bit more work and input on your part. So I totally get that. They may be challenging to do, but certainly consider some of those non-medication interventions as well. Some of them aren't as challenging, for example, like making sure you get some sleep and, and pulling back from electronic devices, things like that are relatively easy to implement. And now if we're talking about medicines, then the first line, and I'm sure you know, this, if you've heard this, this is the first line medication that we do for just about all types of pain in pregnancy, and that's gonna be acetaminophen.

Nicole: That's a generic medication. The brand name of course is Tylenol. Typically we start with the extra strength Tylenol. You can take two of those. So a thousand milligrams at once, and then just follow the directions on the bottle in terms of how frequently that you take it. But acetaminophen has been proven to be safe during pregnancy. Again, we wanna limit it to taking it only when we need to, and for the shortest amount of time possible. Now, if acetaminophen itself doesn't work, then we can add other things with it. So we can do acetaminophen with a medicine called regland. It's a, actually a, a anti nausea medicine we can do acetaminophen with codine. Codine is a narcotic. So we have to be careful about that. We definitely want to limit it because it can actually increase the risk of medication overuse headache, meaning you take the medication for on a regular basis.

Nicole: And when you stop it, then you have, what's called a rebound headache. Also codeine can cause withdrawal from the baby if it's used near term. So you have to be careful about that. The other thing that we also use is something called the brand name is Fioricet, but it's a combination of butalbital, acetaminophen, and caffeine that can also work well during pregnancy too, has some of the same issues as codeine, where you can develop a medication overuse headache, or if you use it too frequently, it can cause withdrawal for the baby near term. So it really should only be used for four or five days out of the month, either one of those in order reduce the chances of those negative outcomes happening. Now, I said in one of those that it's a combination of something called caffeine of a medication that has caffeine Fioricet that has butalbital acetaminophen and caffeine. Know that the caffeine doses in medications for migraines are pretty low.

Nicole: The range from 40 to 50 milligrams, as long as you have a daily caffeine intake of less than 200 milligrams. And that's a very conservative estimate, it can even be more. And that's about the equivalent of two, uh, cups of coffee, roughly. Then you're not likely to have any adverse pregnancy outcomes. And typically caffeine during pregnancy is associated with, um, miscarriage, if it's gonna happen, but it really high doses. So don't, um, stress yourself out that if you're taking this medication with caffeine, that you're gonna have these increased risk because the amount of caffeine is pretty low.

Nicole: Also know that for opioids like codeine, like I talked about, we want to avoid those in the first trimester. There is some limited evidence that they are associated with nervous system malformations in babies. Now, if those don't work, if the, the Tylenol doesn't work, or Fioricet doesn't work, then for short courses, we can try what's called NSAIDs NSAID medications. Non-oral anti-inflammatory drugs like ibuprofen in general, those are avoided during pregnancy and for good reason, because they can affect the baby's kidneys. So definitely do not take that on your own, discuss it with your doctor first, because it can only be given for a short period of time. Okay. And you definitely don't wanna do it. Um, in the first trimester, there's a slightly increased risk of those medications NSAIDs with pregnancy loss and some congenital anomalies, although that's limited evidence, but we know quick, very clearly that in the third trimester, it can have effects on the baby's kidneys, which can lead to low fluid. So we definitely wanna limit that. So don't try any ibuprofen at all during pregnancy, without talking to your doctor about it first.

Nicole: All right. So if those don't work in the shorts term, than the things that we go to next, sometimes we do opioids like oxycodone or hydromorphone, which is Vicodin. And again, same principle, shortest amount of time, lowest effective dose. All right. And we don't wanna use those on a chronic basis because they are addictive and they can contribute be to the development of, um, addiction disorders. So we have to be careful about those as well. Now, a very common medication that is used for migraines outside of pregnancy can be tried during pregnancy. And those are triptans and the most common one is sumatriptan or imitrex. We can try that during pregnancy. Typically that's gonna be with consultation from your neurologist.

Nicole: They are very effective at treating migraines and the human experience, particularly with sumatriptan and pregnancy has been reassuring. A manufacturer's registry for sumatriptan, um, did not show an increased risk of congenital anomalies or early pregnancy loss that was in about 600 patients. And, uh, another study that looked at a review of pregnancy outcomes, following exposure to triptans didn't show any problems or issues, but really we don't have a lot of data with which to base our recommendations on. So you just have to know with that, with that caveat, that it doesn't look like there are any problems, but we don't have a lot of information to make that decision on also because the way they work is that they constrict brain vessels. Maybe there's a theoretical risk. Does it constrict vessels anywhere else in the body? Not that we've seen that, but you do have to be careful about that.

Nicole: So sumatriptan can, can be used Imitrex can be used in certain circumstances, but that's really gonna be in consultation with your neurologist to use it in as safely as a way, use it as safely as possible. This is one of the areas where, you know, as O B GYNs, we obviously know a lot about pregnancy and birth. We can't know how every single condition is going to change in pregnancy. And if you have a problem with severe headaches, this is one where you wanna work or severe migraines. You know, this is one where we would want to work in consultation with a neurologist in order to come up with a plan that works best. Okay. So some other medicines that may help are things that'll can reduce the nausea and vomiting that can accompany migraines like, um, promethazine or Zofran. Uh, Reglan is another one that is typically used as well.

Nicole: Now there are a couple of medications that absolutely should be avoided. One is ergotamine. And I get these generic names. Like sometimes I butcher them. Like, I think I'm saying them right. I don't know if I'm saying it right. So forgive me. They can. I'm like, why, where did you come up with these, these, these names for these medications anyway, so ergotamine or the brand name is cafergot or cafergot. That is absolutely contraindicated during pregnancy, because it can induce what's called hypertonic uterine contractions, and vasospasms, or constriction of the blood vessels to the placenta that can cut off blood flow to the baby. So that one is absolutely contraindicated it during pregnancy. And then Midrin, which is, um, actually a combination medicine, but one of the ingredients, ISO meth Methin that can be used, um, for headache relief outside of pregnancy. So Midrin is absolutely contraindicated during pregnancy. You cannot cannot use that medication because it can compromise uterine blood flow.

Nicole: All right, for the folks that have really bad migraines that aren't responding to those treatments, then sometimes you're gonna need to be admitted to the hospital to get IV hydration, IV medication, to those things under control. Sometimes we add magnesium sulfate through your IV, or, uh, EV and magnesium is something that we also use for other indications, like preterm labor. So we know that it's safe, but it may help stop an acute headache. Also sometimes steroids can be used in really intractable cases to help with the headache as well. Again, that's gonna be in consultation with a neurologist that we do that.

Nicole: All right. Now, if you have really super frequent migraines, then maybe you want to try preventive therapy. Beta blockers are medication that are used for a variety of things. Most commonly for treating blood pressure. Um, beta blockers can be used in severe cases to help prevent headaches. And, uh, their safety has been shown in pregnancy, but you just have to be sure you're on the right one. Also sometimes calcium channel blocker can be used to help prevent headaches as well. Calcium channel blockers are a medication that we sometimes use to prevent, um, high blood pressure in pregnancy, as well as preterm labor.

Nicole: And then finally, um, low dose antidepressants may help with headaches as well, as well as Gabapentin. And then finally something called nutraceuticals where we use food as medicine in a sense can help prevent migraines. The most common ones are magnesium 400 to 800 milligrams daily, riboflavin 400 milligrams daily or extract of butter bur root twice daily can help with preventing migraines during pregnancy. Okay, so I spend a lot of time on migraines because that is the most common one, but some folks also have general tension type headaches during pregnancy. So we're gonna talk about tension type headaches, cluster headaches, the postpartum headaches, and those signs and symptoms, uh, that require prompt, evaluation, and attention as well. So tension type headaches are headaches, where there is like a pressure or tightness in the head, and it can often wax and wane go up and down. Unlike migraine headaches, a lot of people with tension headaches can continue to function and the things that they're normally doing while they have the headache, but some folks may need to rest. Tension headaches will last anywhere from 30 minutes, they can last even as long as seven days too typically though no associated symptoms. So folks don't tend to have nausea or vomiting or, or, or anything like that with a typical tension type headache.

Nicole: Now in contrast to migraine headaches, which usually get better during pregnancy, tension type headaches, usually don't change during pregnancy because they're not hormonally mediated. So in one study, I should say two, um, studies that were really small. It wasn't a people in the study, but roughly like 50 to 70% of pregnant women reported no change in their tension headaches during pregnancy, 30 to 40% reported some improvement four to 5% re reported worsening. So don't expect that if you have garden variety tension headaches, that they're gonna get better during pregnancy because they're not mediated by hormones,

Nicole: Unlike migraine headaches. So doesn't appear to be an increased risk of hypertension or any adverse pregnancy outcomes associated with tension type headaches in pregnancy. There's not a lot of data about it, but from the data that we have there doesn't appear to be any increased risk. And then as far as treatment, it's fairly similar start. We can start with Tylenol, can add Tylenol with codeine or the Fioricet. Like we talked about. We can also do a short course of NSAIDs if needed. We don't do, uh, triptans like the migraine medicines. Those don't work for tension type headaches. So really it's gonna be Tylenol or, uh, Fioricet are gonna be the main ones. And then also the non pharmacologic things that I talked about as well, like avoiding any triggers, getting good sleep. Um, sometimes physical therapy may help in these instances as well.

Nicole: Okay. And then cluster headaches, cluster headaches are not very common. They usually begin around, um, the eye or the temple. They're always on one side. And the pain typically begins really quickly. It gets to its peak within a few minutes, it can be in a pretty excruciating pain, but it doesn't tend to last very long. Also folks can remain active of while they have cluster headaches as well. Unlike the migraine headaches, some, a common associated symptoms are, um, tearing or redness of the eye on the same side that you're having the headache. You can have a stuffy nose, sweating, um, restlessness, agitation, but again, cluster headaches in general are not very common.

Nicole: They also are not affected by reproductive hormones. So they're not going to change typically during pregnancy. Pregnancy, isn't gonna affect the outcome of how you have your headaches. They're just gonna be how they're gonna be. And as far as the effect of cluster headaches or pregnancy outcomes, it actually has not been described or studied because it's just not a common type of headache. Now, the treatment is a little bit different. Actually, the first line of treatment is oxygen. So inhaling oxygen in higher levels actually can help stop a cluster headache. So the first line treatment is oxygen and then a second line treatment is, um, triptans. They can be used as well.

Nicole: All right, let's finish up by talking about postpartum headaches. Now, just like during pregnancy, we still have to consider preeclampsia when someone has a headache, postpartum preeclampsia can happen in the postpartum period. Usually it's gonna happen within the first 48 hours after delivery, but some times it can be a week or more postpartum. So if you have a postpartum headache, preeclampsia is not excluded. So definitely check your blood pressure to make sure you don't have postpartum preeclampsia. Now, with that being said, in general, the postpartum period has a lot going on. There's hormone changes, sleep deprived. You may not be eating on a regular schedule. It can be stressful, you're tired. So all of those things can increase the risk for headaches happening postpartum. So don't be surprised if they return or if you start to have issues postpartum, cuz honestly there's a lot going on now as far as what types of headaches are going to happen.

Nicole: If you had migraine headaches before the postpartum period is a common period of time where they may return, they may not return. It's not a given and I don't have an exact number on percentages of how many people will experience return of their headaches postpartum. But in general know that if you have migraines before pregnancy, it's not uncommon that the postpartum period is when they can't return. And also tension type headaches are very common in the postpartum period as well in terms of the type of headache that happens. Cluster headaches are actually rare. Now for treatment in the postpartum period. If you're not breastfeeding, then you can take all of the same medicines that you were taking when you were, uh, not pregnant before. If you're breastfeeding, then you wanna be careful about the medications and make sure that they don't affect the baby. I'm not gonna go into that in detail, but there's a great resource called lactmed it's L a C T M E D.

Nicole: It's an online resource only. They used to have an app, but the app has since been retired, but Lactmed is a resource to help you with guidance on the effects of medication and breastfeeding. It is a little bit technical and medically in jargon, but it's a great place start. And it's also a reasonable resource for you to bring up with your doctor when you're talking about treating any headaches in the postpartum period while you're breastfeeding, but in general, the same things are gonna be safe. Like acetaminophen is gonna be safe. So you can take that. Um, actually unlike during pregnancy, you can take NSAIDs during while you're breastfeeding. So Motrin ibuprofen, Aleve, Advil, those medicines are totally fine. You do need to be careful about, um, codeine because codeine and all narcotics really can make babies sleepy. So that's even outside of headaches.

Nicole: Folks take codeine to get over, um, postpartum C-section pain or, or if you have a severe tear, you may be taking narcotics. So that's just a general recommendation about narcotics. But if you have more specific, um, questions about triptans or things like that, then lactmed is a good place to look for information. All right? And the other type of headache that can happen postpartum that sometimes people are really surprised about is something called a postural puncture headache, or it's in headache that happens after having an epidural or spinal anesthesia. Typically it can develop within 48 hours after the procedure. So after the epidural or after the spinal and the differences between the epidural or spinal in the short, um, summary is that an epidural is a catheter that's placed and it stays there. Whereas the spinal is a one shot dose of medicine, but both of them carry the risk of having this postural puncture headache.

Nicole: And the headache with this type of condition is worse. When you stand up, it's worse when you raise your head from the bed and characteristically, it improves with rest and laying down, okay? And you don't typically have things like nausea or vomiting associated with it. Those aren't typical for this type of headache. Now the treatment is something called a blood patch and it sounds a little crazy, but it works. But what it does is you take a little bit of your own blood and then the anesthesiologist injects your own blood around the spot where you have the epidural to create a seal. So the spinal fluid doesn't leak anymore. That's the short answer. I know it sounds crazy, but it works really effectively when you have that headache. Also know that this headache can sometimes happen after you leave the hospital and you may have to come back up to labor and delivery or in the emergency room and have that procedure done to fix that postural puncture headache.

Nicole: But it's something that should be considered it if you develop a headache postpartum. Okay. And the last thing I wanna say is there are a few signs and symptoms associated with a headache that really require very prompt and thorough evaluation, cuz they can be more severe signs. And these are gonna make sense. But if you have altered mental status, like you're confused, not knowing where things are, obviously a seizure. If you have a stiff neck, if you have what's called focal neurologic symptoms. So, so for example, say that your whole arm goes numb. That is something that needs to be evaluated promptly and quickly. If it's the worst headache of your life, then definitely get that evaluated. If it's associated with fever, if there was some recent trauma, especially if you hit your head, if you were exposed to some sort of toxins, these are all reasons to get promptly evaluated.

Nicole: If you have a severe headache, headache, um, while coughing or exerting yourself or even sexual activity, those are also reasons to get evaluated. If you have a headache that doesn't go away with pain medication, then definitely touch bases with your doctor. Or if you have a headache that awakens you from your sleep, then also check in with your doctor, cuz it could be signs of more severe problems, typically not, but these are things that you definitely wanna get investigated. And then if you need some sort of imaging procedures in order to evaluate your headache. So if you need an MRI, if you need a CT scan, please don't be afraid to get those done in pregnancy. If need be the risk of exposing your baby to radiation from having an imaging study of your head is very, very low. We can't have a healthy baby if we don't have a healthy mom.

Nicole: And if part of having a healthy you is getting a CT scan or MRI to figure out what's going on with a headache, then definitely 100%. Get it. Similar thing for a lumbar puncture. Lumbar puncture is when there is an suspicion of infection like meningitis and they need to take a little bit of the fluid from around the spine. That risk of that causing any issues with pregnancy is very low and it can give some really important information to help guide your care. So don't be afraid of that either. So, so in general, if there's something that needs to be done to figure out what's going on with the headache, then get it done. Cuz we gotta take care of you in order to take care of baby.

Nicole: Okay. So just to recap, headaches are common in general and they can happen in pregnancy too. For primary headaches, migraines are the most common in thankfully they do get better for most folks during pregnancy, but they will often return postpartum. Folks can also have tension type headaches and cluster headaches during pregnancy, but those are much less common. Generally start with Tylenol for treatment. For most folks, that's gonna be effective, if you need something more than that then working consultation with your doctor and potentially with a neurologist in order to come up with a treatment plan, you just wanna limit medications to the least amount, um, of medication for the shortest amount of time to relieve the symptoms and relieving those symptoms is important. It's important for you to feel good during your pregnancy. And don't forget some of those non-pharmacologic methods as well, rest getting better sleep, heat, ice, relaxation techniques.

Nicole: If there is high blood pressure with a headache, then we gotta evaluate for preeclampsia. Also, if you have associated symptoms like a fever, stiff neck, worst headache of your life, woke you up from your sleep, then go get promptly evaluated. And if you need tests determine what's causing the headache, get the test. Okay, so there you have it. Do me a favor, share this podcast with the friend. If you like it also subscribe to the podcast wherever you're listening to me right now. And if you feel so inclined, leave an honest review, especially in Apple Podcast that helps the show to grow helps other folks to find the show. And I love to hear what you say about the show. Don't forget to check out the Birth Preparation Course. Childbirth education is so, so important. Something you should not skip absolutely should not skip check out all the details of the Birth Preparation Course at drnicolerankins.com/enroll. All right. So that's it for this episode do come on back next week and remember you deserve a beautiful pregnancy and birth.

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