Computed tomography (CT) and magnetic resonance (MR) imaging assist in the diagnosis, classification, and management of many neurological and psychiatric disorders. As discussed in Chapter 46 (p. 907), these imaging methods can be used safely during pregnancy. CT scanning is often used when rapid diagnosis is necessary and is excellent for detecting recent hemorrhage. Because it does not use radiation, MR imaging is oten preferred and is particularly helpful to diagnose demyelinating diseases, arteriovenous malformations, congenital and developmental nervous system abnormalities, posterior fossa lesions, and spinal cord diseases. Whenever either test is done, the woman with advanced pregnancy should be positioned in a left lateral tilt with a wedge under one hip to prevent hypotension and to diminish aortic pulsations, which may degrade the image.
Cerebral angiography with contrast injection, usually via the femoral artery, is a valuable adjunct to the diagnosis and treatment of some cerebrovascular diseases. Fluoroscopy delivers more radiation but can be performed with abdominal shielding. Positron emission tomography (PET) and functional MR imaging (fMI) have not been evaluated for use in pregnant patients (Chiapparini, 2010).
In one national survey in the United States in 2012, 17 percent ofthose aged 18 to 44 years reported a severe headache or migraine within the past 3 months (Blackwell, 2014). Burch and coworkers (2015) reported that 24 percent ofnonpregnant women in this age group were similarly afected. Of pregnant women presenting with headache who received a neurological consultation, two thirds were due to primary disorders, with over 90 percent due to migraine. Of the other third due to secondary conditions, over half were due to hypertensive disorders (Robbins, 2015). Interestingly, Aegidius and associates (2009) reported a decline in the rate of all headache types during pregnancy in nulliparas, especially during the third trimester.
The classification by the International Headache Society (20l3) is shown in Table
In pregnant women, primary headaches are more common than those stemming from secondary causes (Digre, 2013; Sperling, 2015). Migraine headaches are those most likely to be afected by the hormonal changes of pregnancy (Pavlovic, 2017). The incidences ofsevere headache causes in pregnancy are shown in Figure 60-1 .
These are the most frequent cause of all headaches. Characteristic features include muscle tightness and mild-to-moderate pain in the back ofthe neck and head that can persist for hours. Neurological disturbances or nausea are typically absent. The pain usually responds to rest, massage, application of heat or ice, antiinlammatory medications, or mild tranquilizers. Hospital admission is seldom necessary.
The term migraine describes a periodic, sometimes incapacitating neurological disorder with episodic attacks ofsevere headache and autonomic nervous system dysfunction (Goadsby, 2015). The International Headache Society (20l3) classifies
TABLE 60-1. Headache Classification
Disorders of homeostasis
Data from International Headache Society, 2013.
Pituitary, 3.6%
Infection, 2.1% Stroke, 2.8% Other headache, 6% (tension 3%) Migraine, 59% With aura, 37% Without aura, 24••• Chronic, 6%
FIGURE 60-1 Incidences of headache causes in 140 consecutive pregnant women for whom in-hospital neurology consultation was requested. (Data from Robbins, 201o5.) three migraine types based on chronicity and on the presence or absence ofan aura.
1.