A 25-Year-Old Pregnant Woman With Worsening Headaches

Nancy Hammond, MD


June 07, 2018

When a patient presents with classic symptoms of migraine, imaging should only be performed when clinical signs or symptoms are suggestive of a secondary headache. The following symptoms and signs could be a marker for a more serious cause of headache:

  • An abnormal neurologic examination, including presence of papilledema

  • Abnormal mental status

  • Thunderclap headache (a headache that suddenly reaches maximal intensity)

  • Headache associated with positional changes

  • New-onset headaches

  • A substantial change in headache characteristics or pattern

  • Signs of systemic disease (eg, fever or weight loss)

Neuroimaging is usually normal in migraine. White-matter T2 and fluid-attenuated inversion recovery (FLAIR) hyperintensities are seen more commonly in patients with migraine with aura. The pathologic mechanisms responsible for these changes are not known. Pathologic studies have shown gliosis in these lesions. These lesions do not correlate with migraine severity or frequency or have any other symptom correlation.[3]

This case brings up an interesting dilemma in treatment of migraine in young women who are or may become pregnant. Fortunately, migraine improves for most women during the second and third trimester of pregnancy.[4] Unfortunately, both preventive and acute treatments for migraine are limited during pregnancy due to teratogenic potential.

Several causes are responsible for secondary headaches in pregnant women. Cerebral venous thrombosis presents as a nonspecific but constant headache that often worsens over time (Figure 2).

Figure 2.

Usually, other focal neurologic deficits or seizures are present. When a pregnant woman presents with headache, hypertension, proteinuria, and eclampsia should be considered. The headaches in these cases are typically severe and not responsive to analgesics. Posterior reversible encephalopathy and reversible cerebral vasoconstriction are possible serious complications of eclampsia. Pregnant women are also at risk for ischemic stroke. Ischemic stroke is more common in women with diabetes mellitus, sickle cell disease, hypertension, and pre-existing heart disease.

Pituitary apoplexy is a rare cause of sudden-onset severe headache due to infarction and hemorrhage of the pituitary gland. Pituitary apoplexy is typically seen in the presence of pituitary adenoma; however, physiologic pituitary hyperplasia during pregnancy can also result in pituitary apoplexy. Associated symptoms include nausea, vomiting, and visual disturbances.

Idiopathic intracranial hypertension can also present during pregnancy. Symptoms of this disorder include headache, transient visual obscurations, particularly when bending forward, and pulsatile tinnitus. Fundoscopic examination reveals papilledema (Figure 3).

Figure 3.

Once neuroimaging is performed and no space occupying lesion is seen, lumbar puncture with opening pressure should performed. The presence of elevated cerebrospinal fluid pressure is diagnostic of idiopathic intracranial hypertension.

The young woman in this case has had headaches that have become more frequent since she became pregnant; however, she had a normal neurologic examination, which is reassuring, and prior neuroimaging did not show any significant findings.

Careful consideration should be given to the need for neuroimaging during pregnancy. If neuroimaging is deemed necessary based on history and physical examination, MRI is typically preferred over CT. Use of either iodinated contrast or gadolinium-based contrast is not recommended. If imaging is needed, the risks and benefits should be discussed with the patient.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.