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  • How do you recognize a concerning headache that needs imaging?

  • How do you differentiate among the common primary headache disorders (migraine, tension, cluster, etc.)?

  • What are the treatment options for chronic benign headache during pregnancy?

CASE 28-1

A 32-year-old G1P0 female with a history of migraine headaches who now presents to L&D at 31 3/7 weeks estimated gestational age with a severe headache. Her pregnancy has been unremarkable thus far except for excessive weight gain of 60 pounds, with her migraine headaches improved during pregnancy while on prophylactic metoprolol. She reports that this headache started two days ago, has been getting worse, and is unrelieved with acetaminophen and sumatriptan. Today, she started to hear a constant “whooshing” sound in her ears and had two brief episodes of double vision.

  • What components of the physical exam are important in this case?

  • Is further diagnostic testing indicated?

  • What are potential treatment options?

Headache disorders are listed as the third-highest cause of disability worldwide in the 2013 Global Burden of Disease Study.1,2 It is reported that up to 20% of all women have a primary headache disorder, up to 60% of women reported suffering from headache within the past year, and up to 80% have experienced headache at least once in their life.35

There are nearly 100 different classifiable types of headache. Fortunately, 90% of headaches in pregnancy are benign migraine or tension headaches.6,7 Other benign primary headaches are cluster headache and analgesic overuse headache. These headaches do not have significantly adverse outcomes in pregnancy, save for some rare reports of increased risk of preeclampsia and low birth weight in those with migraine headaches.

However, secondary and pathological headaches also manifest themselves in pregnant women more frequently than in nonpregnant adults.8 These include preeclampsia and eclampsia, cerebral hemorrhagic or thrombotic vascular event, raised intracranial pressure through brain tumor or other intracranial hypertension conditions, and intracranial infections. It is imperative that the clinician differentiates between benign headache and serious headache by appropriately identifying concerning history and physical exam findings that would result in more specialized workups such as laboratory studies, imaging studies, and neurological consultation.


TABLE 28-1Secondary (Malignant) Headaches

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