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Headache in Pregnancy Evaluation Wizard, Algorithm, Teaching Module, and Quiz

Wizard Clinical Algorithm Structured Inputs Teaching Module Management by Category Quiz

Headache in Pregnancy BETA

Interactive decision support for evaluation of headache during pregnancy and the postpartum period. This tool helps screen for hypertensive disorders of pregnancy, PRES/eclampsia, cerebral venous thrombosis, subarachnoid hemorrhage / thunderclap headache, meningitis, post-dural puncture headache, and intracranial pressure disorders, while also recognizing common primary headaches such as migraine and tension headache.

Expanded wizard Visible algorithm Red-flag screening Imaging notes Management tabs 6-question quiz
New, severe, refractory, positional, thunderclap, or neurologically abnormal headache in pregnancy or postpartum should be treated as a potential secondary headache until proven otherwise.

Interactive Yes/No Wizard

Start: Is the blood pressure severely elevated or are there preeclampsia symptoms?

Think severe BP, visual symptoms, RUQ pain, edema, hyperreflexia, or a headache that will not go away.
Path: Start
Choose Yes or No to begin.

Visible Clinical Algorithm: Headache in Pregnancy

Start here

Any new, severe, sudden, refractory, positional, or atypical headache in pregnancy or postpartum should trigger evaluation for secondary causes before labeling it as migraine or tension headache.

Step 1. Look for emergency clues

Red flags Severe hypertension, seizure, confusion, focal deficit, visual loss, thunderclap onset, fever, meningismus, postpartum state, papilledema, Valsalva worsening, or thrombosis risk.
↓
If present Treat as secondary headache until proven otherwise.

Step 2. Follow the main branch

Hypertension + headache ± vision changes Think preeclampsia, eclampsia, or PRES.
Thunderclap onset Think subarachnoid hemorrhage, hemorrhage, or reversible vasoconstriction syndromes.
Postpartum + severe headache + thrombosis risk Think cerebral venous thrombosis.

Step 3. Other important branches

Positional / worse upright Think post-dural puncture or CSF pressure headache.
Papilledema or worse with Valsalva Think increased intracranial pressure, CVT, IIH, or mass lesion.
Similar to prior migraine and no red flags Primary headache becomes more likely.

Structured Inputs

Interpretation

Teaching Module

1. Red flags for secondary headache +
New headache
Severe headache
Thunderclap onset
Seizure
Focal deficit
Severe BP
Fever / neck stiffness
Postpartum
Papilledema
Positional
  • Elevated blood pressure and abnormal neurologic examination are important red flags for secondary headache.
  • Pregnancy and postpartum status themselves lower the threshold for further evaluation.
  • A completely new headache pattern in pregnancy deserves more caution than a familiar migraine pattern.
  • Papilledema or Valsalva-worsened headache raises concern for intracranial pressure disorders.
2. Hypertensive headaches in pregnancy +

Headache that will not go away, especially with visual symptoms, hypertension, RUQ pain, abnormal labs, or neurologic change, should raise concern for preeclampsia with severe features, eclampsia, or PRES.

Finding Why it matters
BP ≥140/90 Supports hypertensive disorder of pregnancy in the right clinical context.
BP ≥160/110 Severe-range blood pressure is an emergency trigger.
Visual symptoms May indicate severe features, PRES, or other neurologic involvement.
Platelets low / AST or ALT elevated Suggests preeclampsia with severe features or HELLP spectrum disease.
3. Imaging safety in pregnancy +

MRI is generally preferred when it answers the clinical question, but a clinically indicated CT head should not be withheld because of pregnancy if emergent intracranial disease is suspected.

  • MRI brain is useful for venous thrombosis, PRES, pituitary disease, and many secondary headaches.
  • CT head is appropriate when hemorrhage or other emergent intracranial pathology is a concern.
  • Do not delay urgent neuroimaging for thunderclap headache, focal deficit, seizure, or papilledema.
4. Important secondary causes to remember +
Pregnancy-related / higher risk in pregnancy
  • Preeclampsia / eclampsia / PRES
  • Cerebral venous thrombosis
  • Post-dural puncture headache
  • Pituitary apoplexy
General neurologic emergencies
  • Subarachnoid hemorrhage
  • Intracerebral hemorrhage / stroke
  • Meningitis / encephalitis
  • Mass lesion / intracranial pressure disorder / IIH

Management by Category

Hypertensive disorder of pregnancy / preeclampsia pathway

  • Recheck BP and assess for severe features immediately.
  • Obtain CBC, platelets, creatinine, AST/ALT, and urine protein assessment.
  • Consider magnesium sulfate and urgent obstetric management if severe features are present.
  • Neurologic symptoms, visual changes, seizure, or altered mental status raise concern for PRES/eclampsia.

Cerebral venous thrombosis pathway

  • Consider especially in the postpartum period or with thrombophilia, dehydration, or infection risk.
  • MRI with venous imaging is often useful when available and appropriate.
  • Severe progressive headache, focal symptoms, seizure, or papilledema should lower the threshold for urgent neuroimaging.

Thunderclap / hemorrhage pathway

  • Treat thunderclap headache as an emergency.
  • Urgent neuroimaging is indicated.
  • Do not dismiss sudden maximal-onset headache as migraine without evaluation.

Infection / meningitis pathway

  • Fever, meningismus, photophobia, or altered mental status increase concern.
  • Urgent evaluation and appropriate infectious workup are indicated.
  • Sepsis, encephalitis, and meningitis should remain on the differential.

Positional / post-dural puncture headache pathway

  • A clearly positional headache, especially worse upright and better lying down, raises concern for CSF leak-related headache.
  • Review recent neuraxial anesthesia, spinal procedure, or lumbar puncture history.
  • Escalate if the presentation is atypical, severe, or associated with neurologic findings.

Intracranial pressure / papilledema pathway

  • Papilledema or headache worse with Valsalva, cough, or strain raises concern for increased intracranial pressure.
  • Consider CVT, idiopathic intracranial hypertension, or mass lesion depending on the clinical context.
  • Urgent funduscopic review and neuroimaging strategy may be needed.

Primary headache pathway

  • More likely when the pattern is similar to prior migraine and no red flags are present.
  • Still reassess BP and neurologic status in pregnancy.
  • Escalate if the headache becomes atypical, refractory, or associated with new symptoms.

Quiz Module

1. A 34-week patient has severe headache, BP 168/110, and visual changes. What is the most concerning category?

2. Which pattern should prompt immediate evaluation for hemorrhage?

3. Postpartum severe headache plus thrombosis risk should raise concern for:

4. A headache that is clearly worse upright and improves when lying down most strongly suggests:

5. Papilledema or headache worse with Valsalva should raise concern for:

6. Which feature is more reassuring for a primary headache pattern?