In Search of the Best Pain Clinic in LA: Headaches During Pregnancy

By | January 25, 2012

The headaches and nausea of pregnancy can become so severe as to endanger the wellbeing of mother and baby.

Headaches are probably the second most common chronic pain disorder in pregnancy, right behind back pain, but perhaps the most serious. The way that the best pain clinic in Los Angeles would deal with these difficult patients is instructive of the way that they would approach their other patients. Severe headaches are common in pregnancy especially among patients with preexisting headache syndromes. When severe these headaches are often accompanied by nausea and vomiting that can be so severe as to necessitate intravenous therapy to prevent dehydration. Fluid and electrolyte imbalances brought on by prolonged bouts of nausea and vomiting can directly endanger the life and wellbeing of mother and baby. In severe cases the women may need to be hospitalized creating social problems on top of the medical ones, especially if there are other children at home.

The work up of these headaches during pregnancy is similar to those occurring in the non-pregnant state except that the threshold for ordering imaging studies is much higher. In both cases we begin with a detailed history and a complete physical examination. If there are suspicious details in the history or if the physical exam reveals a focal neurological deficit the patient should be referred to a neurologist and imaging studies ordered immediately despite the risk to the fetus. In most patients this is not the case and imaging studies can be deferred until after delivery and the headaches treated anatomically.

Headaches that begin in the neck or back of the head are treated like cervicogenic headaches. Greater and lesser occipital nerve blocks with just local anesthetics are surprisingly effective and relieving pain and stopping the nausea and vomiting. Steroids are generally avoided until the third trimester. While technically possible under ultrasonic guidance, median branch blocks and radiofrequency ablations are rarely done due to poor visualization and difficulty with positioning. Transcutaneous electrical nerve stimulation therapy is rarely effective due to considerations of hair and muscle depth. Anterior headaches can often be treated with trigger point injections of local anesthetics and TENS therapy, which is effective here due at least in part to the shallow depth of the nerves in this area. Botox is contraindicated due to possible neurotoxic effects on the fetus. It is amazing how many patients can be helped by these simple measures and extremely gratifying to see the pain and nausea stop and watch the pregnancy from hell get back on track.

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