Headache in Pregnancy and the Puerperium

Migraine is the most common cause of headache during pregnancy. Pregnancy increases risk for many causes of headache, including pathologic vascular processes. Headache associated with neurologic signs or symptoms or that is progressive and refractory to treatment; acute in onset; and severe, postural, or different from typical headaches should be evaluated. Work-up should include cerebral and cerebrovascular imaging and monitoring for hypertension. Acetaminophen is first-line symptomatic treatment during pregnancy, and evidence supports triptans rather than butalbital combination analgesics as second-line treatment. Propranolol is preferred preventive treatment, and amitriptyline and verapamil may be considered. Treatment of migraine during lactation is less restrictive than during pregnancy.