The classic presentation of migraine is with a paroxysmal unilateral headache preceded by visual and sensory phenomena, accompanied or followed by nausea and vomiting. Migraine may present for the first time during or shortly after pregnancy.
Problems and special considerations
Migraine often improves in pregnancy but recurs in more than 50% of women postpartum. Many women are anxious about how labour and the pain-relieving drugs given in labour will affect them, and may seek advice as to whether regional analgesia is a problem.
Many drugs used for migraine cross the placenta, and drug therapy may need altering during pregnancy.
Stress, including pain and starvation, can precipitate an attack of migraine.
An acute migraine attack presenting with severe headache and visual disturbances may be confused with pre-eclampsia. Rarely, migraine may be associated with other neurological symptoms.
In the postpartum period, migraine may be confused with postdural puncture headache (PDPH); indeed, the cerebral vasodilatation that is thought to cause the headache of migraine may in part be responsible for the headache that follows dural puncture.
Management options
There is no contraindication to epidural or spinal analgesia or anaesthesia.
Migraine can usually be easily distinguished from PDPH. In migraine, the headache is usually unilateral and frontal, whereas in PDPH the headache is usually bilateral, occipital and frontal. The dramatic improvement in PDPH on lying down is not present with migraine. New-onset severe headache should always alert medical staff to the possibility of other underlying conditions (see Chapter 45, Postdural puncture headache).
Key points
• Migraine is common but often improves during pregnancy.
• Migraine may resemble pre-eclampsia and postdural puncture headache.
• Anaesthetic management is routine.
Further reading
Contag SA, Bushnell C. Contemporary management of migrainous disorders in pregnancy. Curr Opin Obstet Gynecol 2010; 22: 437-45.
Goadsby PJ, Goldberg J, Silberstein SD. Migraine in pregnancy. BMJ 2008; 336: 1502-4.
Klein AM, Loder E. Postpartum headache. Int J Obstet Anesth 2010; 19: 422-30.
Pearce CF, Hansen WF. Headache and neurological disease in pregnancy. Clin Obstet Gynecol 2012; 55: 810-28.