S4 E2: Pregnancy and breastfeeding 2

A National Migraine Centre Heads Up Podcast transcript

Pregnancy and Breastfeeding 2

Series 4, episode 2

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[00:00:00] Did you know that some women stop having migraine attacks during pregnancy whilst others get their first ever aura? Estrogen is the key hormone involved.


[00:00:16] Welcome to the Heads Up podcast brought to you by the National Migraine Centre, the only UK charity treating migraine and headache.


Dr. Katy Munro [00:00:25] Welcome everybody to this episode of the podcast and today we’re going to be talking about headache in pregnancy and breastfeeding. We’ve done an episode previously about migraine in pregnancy, but we wanted to explore a little bit more around what’s useful to take for migraine, what you should avoid, but also more on the secondary headaches, which aren’t migraine. And I’m very pleased to welcome Dr. Pooja. Dassan. Would you like to introduce yourself, Pooja?


Dr. Pooja Dassan [00:00:55] Thank you, Katy. Yes. So I’m a neurologist and I work in northwest London and I’ve developed a sort of niche specialist interest in obstetric neurology. What does that mean? Essentially, I see pregnant women, but also women that are planning a pregnancy, if they have pre-existing neurological problems, that might be migraines, any other types of headache, epilepsy, and they are pregnant or planning a pregnancy because there’s lots to discuss. There’s, of course, the condition itself and how that might impact on the pregnancy, the pregnancy impacting on the condition and of course, the drugs that they might be on. And I find pre-conception counselling, that’s seeing them before they plan the pregnancy, particularly if they’re on drugs, particularly helpful as we can really optimise the drug therapies to try and minimise risks. And then often I also see them post-natally, particularly if I’ve made any drug changes in pregnancy, just to follow that through. So a vast majority of patients that we see actually have headaches just because headaches, particularly migraines, are pretty prevalent in women of childbearing age.


Dr. Katy Munro [00:02:01] Yes, very common, aren’t they? Very common. And I have heard some patients say that they are a bit scared to get pregnant because they don’t know whether their migraine is going to get worse or whether their medication they’re taking is going to be stopped. So the pre-conception advice that you would give could range from all sorts of things, I’m guessing? What sort of things would you discuss with them in your clinic?


Dr. Pooja Dassan [00:02:26] The first thing I would do would probably just, being a neurologist, I’d confirm the diagnosis and that doesn’t take very long. And then how we’d go about it. Well, certainly if they are on medications that we might deem to be what we say teratogenic, which means harmful for the baby, may cause malformations in the baby. And the two top ones are drugs that are used for prevention. So sodium valproate, otherwise known as epilim, or topiramate. These drugs are used in women to prevent migraines, and if the patient is taking those, we would counsel them that they would be at higher risk of that causing problems with the baby and we’d advise them to come off. Now, that could be a shock to the system because these medicines can work quite well in terms of migraine prevention. So how are we going to manage things? Well, there are alternatives and certainly, particularly in terms of preventatives that are safe to take and we can counsel the patients about that. Beta blockers such as propranolol are entirely safe to take in pregnancy. Often don’t require that large doses and people worry about blood pressure because beta blockers are also used to drop blood pressure. And we keep an eye on that because pregnancy can lead to low blood pressures. Actually, I have a patient that I was speaking to just yesterday who’s just fallen pregnant, taking propranolol, and she’s feeling very dizzy on it for the first time, and that’s just because naturally her blood pressure has dropped in pregnancy. So that’s important to be aware of because the doses that you were on before might be too much for you in pregnancy.


Dr. Katy Munro [00:03:46] Can I ask you about beta blockers? So there are a number of different beta blockers. Propranolol, metoprolol, atenolol and timolol are all different ones. Is there any one that you would say you prefer that one in pregnancy or does it not matter?


Dr. Pooja Dassan [00:04:01] I personally use propranolol most commonly and that’s just because we have more data on propranolol. And propranolol is a drug that’s commonly used by obstetricians in pregnancy as well, as well as other drugs, such as labetalol, for blood pressure control in pregnancy patients who develop gestational hypertension. So given that we have more information regarding propranolol, it is my preferred choice.


Dr. Katy Munro [00:04:22] That’s really useful.


Dr. Pooja Dassan [00:04:23] Alternative preventatives that can be used and are safe would be tricyclic antidepressants such as amitriptyline and nortriptyline. My preference is actually nortriptyline, even outside of pregnancy. I find it’s just got a- it’s better tolerated, a better side effect profile. It’s a little bit more expensive than amitriptyline, but certainly it’s better tolerated and we don’t need to often go very high, low doses starting at 10 milligrams a night and then just increasing that is usually enough. And if the patient is having problems with sleep or, you know, has a tendency to low mood or a bit of anxiety, then that might be a preferred choice because you can sort of tackle other issues with it as well. Propranolol, of course, should be avoided if they have asthma.


Dr. Katy Munro [00:05:07] Yes, I think we use amitriptyline and nortriptyline quite commonly, but, as you say, it’s a little bit of a cost effect and I know sometimes GPs would rather patients started on amitriptyline because it’s a little bit cheaper, isn’t it? But the daytime sleepiness the following day can sometimes be a nuisance which you don’t tend to get so much on nortriptyline.


Dr. Pooja Dassan [00:05:28] Correct. I find that too. Absolutely. And then patients often want to know, well, what abortive treatments can I take for my migraines? You know, I’ve been told that medicines can be harmful for the baby, what’s safe, what’s not? It’s a common question. And of course paracetamol is safe, but paracetamol is not particularly helpful in aborting bad migraine attacks, but it is safe. I’m often asked about non-steroidal medications that’s like ibuprofen or naproxen. Now, contrary to what common knowledge is, actually, you can take non-steroidal medications, that’s ibuprofen, up to 28 weeks. It’s actually only after that that we worry about it interfering with baby’s circulation. But before that, it’s fine. And just remembering that these drugs are fine to take and safe to take. But it’s important that they are not taken too often. So daily intake, as it is the case outside of pregnancy, can certainly lead to medication overuse headache. And that’s a phenomenon whereby you get a rebound pain as a result of taking medicines more than, say, three or four days a week. So that’s important to bear in mind.


Dr. Katy Munro [00:06:32] We see that- it’s quite a common problem, especially with things like the triptans. And then occasionally, unfortunately, we see people who’ve been taking codeine for their migraines. What would you say about that? I can see by your expression you agree with me that that’s not something we’d encourage at all.


Dr. Pooja Dassan [00:06:51] That’s right. Yes. Your listeners can’t appreciate the expression there. So thank you for pointing it out. That’s right. Codeine is not a good medicine, even outside of pregnancy, for migraine patients. It exacerbates the nausea and vomiting that comes with it. It leads to a dependency. And of course, as you correctly pointed out, more risky in terms of developing medication overuse headaches. So on many counts, although obstetricians think it’s an entirely safe analgesic to take in pregnancy, we don’t particularly like it for our migraine patients. But triptans, you mention, again, a lot of discussion happens about this and a lot of my colleagues that don’t see pregnant women as much as I do will often advise patients to stop their triptans. But triptans can work wonderfully for some of our patients. It’s the only thing that’s going to abort their headaches, and we just don’t want them to suffer during their pregnancy if they don’t have to. And there’s a lot of evidence now for sumatriptan, which is the commonest used triptan which we extrapolate to some degree to the others, although we’re getting a little bit more research and information about the others. And remembering that actually most of the information we get is from pregnancy registry data where women have been taking medicines, inadvertently found out they’re pregnant, and then we find out what happens in terms of foetal outcomes. And sumatriptan is really quite safe and no adverse outcomes have been noticed, no birth weight or malformations. So contrary to what women often think, there are actually quite a few options for them in pregnancy. And hopefully by talking to them as part of their pre-conception counselling, you can reassure them of that.


Dr. Katy Munro [00:08:23] I think I’ve certainly had some patients who’ve breathed a sigh of relief when they’ve come to clinic to speak to us about the fact that they’re either trying to get pregnant or in early pregnancy and they’ve been told they shouldn’t have any of their triptans. And we say, Yes, you actually can do that, you can take those. And they’re like, Oh, thank goodness for that. It’s a huge relief, especially if they’re trying to function with other children in the family to look after. What about aspirin? Do you think that aspirin is safe? Because I know some women are given aspirin in small doses if they’ve had recurrent miscarriages, aren’t they?


Dr. Pooja Dassan [00:08:55] That’s correct. Yes. So aspirin is used for that indication. Aspirin is also used, usually if trusts have different policies. But certainly if the maternal age is about the age of 35 or 40 and it’s used for patients who’ve had pre-eclampsia before, that’s hypertension with protein in your urine. So obstetricians actually love aspirin. There’s a funny story to this. So when I started doing this obstetric neurology clinic, as all neurologists do, I would procrastinate over every drug. And when it came to aspirin, the obstetrician almost picked up the folder and hit me on my head with it and said, We just love the stuff. And I say it in jest, but aspirin at low doses is something that’s prescribed quite frequently in antenatal clinics for the reasons I’ve indicated. And actually interesting enough, when I also joined the clinic, the obstetricians were commonly using low dose aspirin, at doses of 75 milligrams, baby aspirin, for prevention of migraines, which I found quite interesting because we’ve never used that outside of pregnancy. And of course we use aspirin at high doses to abort headaches, doses of 600 or even 900 milligrams dispersable aspirin for women that can take it and have no contraindication to it. But this low dose as prevention was quite astonishing to me. And I went and looked at the data and there is no robust evidence for this. But many obstetricians will use this and tell you that it’s quite effective. And I guess it sort of takes us back to migraine having traditionally being thought of as a vascular sort of headache. And I wonder if it stems back to that. But in any case, no robust evidence, but obstetricians do seem to think it works.


Dr. Katy Munro [00:10:27]  That’s really interesting. So would you advise somebody that it’s quite safe to use aspirin as an abortive in those high doses you mentioned of 600 to 900mg, right the way through pregnancy? Or do they have to be a bit careful at the end in the same way they do with the non-steroidals?


Dr. Pooja Dassan [00:10:42] That’s entirely correct, but for different reasons. So aspirin can be taken during pregnancy, but often, even if patients are on high dose aspirin for pre-eclampsia prevention, for example, up to 150 milligrams, that will normally be stopped around the third trimester, about 35/36 weeks. And the risk is associated with bleeding. So we don’t want to put Mum at any increased risk of bleeding during labour or postnatally. But it is safe to take aspirin early on, but certainly not while they’re breastfeeding. Aspirin can be harmful for the baby.


Dr. Katy Munro [00:11:13] Are there any supplements? So people are often taking lots of vitamins and minerals and things, certainly just from day to day even before they’re pregnant. Are there any specifically that you would say could be helpful for migraine prevention in pregnancy?


Dr. Pooja Dassan [00:11:28] Yes. Going to the non-pregnant state, the nutritional supplements that are commonly recommended by those who have a special interest in migraines and headaches are vitamin B2, that’s riboflavin, and often high doses of that so patients that are on multi-vitamins, there’s not enough of it in there. You have to go out and seek the vitamin B2 on its own and it’s normally a suggestion of 400 milligrams a day of vitamin B2. It does turn your urine fluorescent yellow. I often warn patients that’s something to look forward to so they’re not alarmed by it. That sort of high dose, not much evidence regarding its safety. It’s fair to say that excess of vitamin B2 is just peed out and hence you see it in your urine. But there isn’t much evidence with regards to its safety. But magnesium is a good one, so magnesium is quite helpful for migraine prevention and magnesium is commonly used in various conditions but more commonly used in pregnancy, particularly in patients that develop pre-eclampsia. Magnesium supplements would be absolutely fine to continue with.


Dr. Katy Munro [00:12:28] Yeah, I’m a big fan of magnesium and I usually do recommend that for people, whether they’re pregnant or not. It often does seem to help. And the riboflavin as well. So that’s really interesting. So migraine, of course, is a primary headache, and primary headaches are the cause of the headache. But then there are certainly a number of people who develop secondary headaches in pregnancy. What are the most common types of secondary headaches that you would see or can you tell us a bit more about that?


Dr. Pooja Dassan [00:12:57] Of course, yes. So I guess I should just start by visiting the definitions of these. What do we mean by primary and secondary? So primary headaches, as you correctly said, migraines, tension type headaches, cluster headaches, i.e. there’s unlikely to be or there isn’t a dangerous cause underlying them, unlikely to be something on their scan or anything physiological that’s underlying it. A secondary headache is more likely to be due to an underlying cause, such as a space-occupying lesion in the brain, sadly, a brain tumour sometimes causing a headache, a blood vessel abnormality so an aneurysm or a malformation of the blood vessels, a bleed in the brain that’s occurred acutely and catastrophically, or a clot even in one of the blood vessels. So these are the sort of secondary causes that would alert a doctor reviewing that patient to- particularly if they’ve come in acutely- to admit, investigate and then treat. And what becomes quite an issue, particularly when the patient is pregnant and they have a pre-existing primary headache such as a migraine, and then they come in with an acute headache and then it’s the doctor’s job to really work out, well, is this just another migraine attack or is this a secondary cause? Because just because you have migraines doesn’t mean you can’t have another cause for that headache. And that can be quite difficult to tease out. And it’s certainly something as a neurology registrar, when you get called to see a patient on the labour ward or in the antenatal ward, it’s something that always concerns you. Is there another cause here? Because as I’ve already alluded to, migraines are so common in women of childbearing age. At least one in four will already have had migraines in their pre-pregnancy state. So the sorts of things that we could alert a pregnant woman to think about or be vigilant of, is if they do develop a headache, is the headache very different in character or severity to their usual migraine headache? That would suggest they should probably get this looked at. And if it’s changed acutely and suddenly, then definitely get it checked out then and there. If that means visiting A&E so be that. It could be a secondary cause underlying it. And that’s a dramatic change. The other definition of something possibly sinister going on might be a headache that we, in the profession, call a thunderclap headache. What I mean for that is a headache that literally comes on like a clap of thunder and is maximum intensity within a minute or two of starting. And that acute onset headache, which is reaching its severity so quickly, would be of concern. So if the pregnant woman was to develop that, she shouldn’t be hanging around waiting to ring the GP on a Monday, if that occurs Friday night. That requires, of course, urgent attention. Take yourself to A&E. And then of course, if the headache is associated with any significant features, the nausea and vomiting is just relentless more than it normally would be, if they’re developing any stiffness around their neck or anything like that, if they’re just not feeling right, it feels very different to what they normally feel like that should alert them. And then lastly, features that may have come on a little bit more slowly perhaps, but features of the headache where, you know, it’s worse when you’re straining on the toilet, it’s worse when you’re coughing, it’s worse when you’re sneezing, and it stays worse for a while after you do those things. That sort of headache would suggest that you probably need to get it checked out. It might suggest a pressure issue, a high pressure issue within the brain. So those are the sort of things certainly the doctor would be trying to elicit from the patient. But equally so, those are the sort of things that a pregnant woman should look out for in herself just to try and work out if the headache is different to her usual.


Dr. Katy Munro [00:16:30] Yes, it’s not something we tend to see at the National Migraine Centre and I think because the headaches you described normally do take women to see somebody urgently, either their GP or they go down to casualty if it’s come one with the severity that you describe. But there are some women who don’t have a pre-existing history of headache and develop new headaches in pregnancy, and that could be new migraine.


Dr. Pooja Dassan [00:16:59] That’s absolutely right. And the primary reason for that, Katy, of course, is because migraines and our hormones are very closely linked. And we know that estrogen is one of the main culprits for women. And what happens is the estrogen levels can be quite high by second and third trimester and women can present for the first time with their migraine type headaches. But equally and more confusing sometimes for the doctors is that they can present for the first time with migraine with aura, and by that I can mean an associated symptoms such as maybe loss of vision, zigzag lines in their vision, weakness even on one side, which can be quite confusing for the patient and equally the team seeing them whether this is a first presentation of their migraine with aura during pregnancy or alternatively whether there may be a secondary cause that I’ve alluded too. And I guess it’s an important time to probably mention what sort of secondary causes we are talking about. I mentioned the sort of symptoms to look out for, but the sorts of things that we worry about, particularly in pregnant women, is clots in the brain, number one. And the reason for that, Katy, is of course that pregnancy is a pro-thrombotic state by which I mean the blood is extra sticky and much more likely to clot and it remains so. You remain pro-clotting till about six weeks after you’ve given birth. And that’s in a normal pregnancy. Clots can happen in blood vessels, particularly the veins, the cerebral veins that drain blood away from the brain. And you can imagine if a clot sits in a vein that’s draining blood away from the brain, the pressure would build up in the head and that would cause headaches. And those headaches typically cause these high pressure symptoms that I alluded to earlier with pain worse when you’re lying down, when you’re coughing, when you’re straining or sneezing and that’s why we ask patients about those symptoms. Another cause of secondary headache in pregnancy can be infection. And the reason I say that is because pregnancy is what we call an immunosuppressed or an immunocompromised state. And it kind of has to be because otherwise the mother would reject the baby. The baby is a foreign object in her, and unless she was a little immunocompromised, she would reject the baby in various ways. Her body would. The by-product of that is, of course, that you are therefore a little more prone to infections. And that’s why we need to look out for whether this could be an infection in the brain, a meningitis or an encephalitis. That can be a cause of a secondary headache. That’s a little more common in pregnancy than it would be outside of pregnancy for these young women. Another cause could be a bleed. And the reason I mention about it being more common, particularly in young women in pregnancy, is because the woman’s output from her heart has to increase because she’s carrying another life within her. So she has to be able to supply more blood around. And that increase in, what we call, cardiac output can cause, particularly if there is a little weakness in one of the brain blood vessels already that’s giving her an obvious predisposition, she can go on to bleed as a result of that. So those are the sorts of things that we normally look out for. And the symptoms that I’ve already alluded to, that both the doctor and the patient should remain vigilant for.


Dr. Katy Munro [00:20:07] So all of those things sound quite scary actually. And I know if patients are suddenly developing new headaches in pregnancy, it can be quite alarming. The last thing you want is to have to go off to hospital when you’re pregnant and be worrying about things. Can you give us an idea of how commonly a headache in pregnancy is something to worry about? Is there a kind of generalisation compared to migraine?


Dr. Pooja Dassan [00:20:31] Okay, so very good point. Very, very uncommon. So we are talking less than 1% of the headaches that we actually see will have a secondary sinister cause. And we can put our patients at rest about that. The commonest cause will be primary headaches and most women will have a pre-existing disorder which can help us to make that diagnosis. You’re absolutely right. We don’t want to alarm our listeners by any means, but I guess it’s just important that they’re aware that just because they have a migraine disorder already, they should always be alerted to the fact that if the headache changes in any way, they should get it checked out.


Dr. Katy Munro [00:21:07] Yeah. You mentioned earlier on, I wanted to just come back to it, the primary headache called cluster headache. So we have a number of patients who come to us, not necessarily pregnant patients, who have really struggled to get a diagnosis of cluster headache, because I think there’s quite a lot of confusion about- some of them have been told that they have migraine, some of them have been told that they have cluster migraine, which is a phrase that we don’t really like to use because it’s too confusing. But cluster headache is a completely different primary headache from migraine. Does anything change when you’re pregnant if you have cluster headache as a pre-existing condition?


Dr. Pooja Dassan [00:21:47] That’s right. Cluster headaches we don’t see that much in women. It doesn’t have the same female preponderance that migraines do. It has a male preponderance. But that doesn’t mean that we don’t see women with cluster headaches and as you say, also in pregnancy. And cluster headaches present very differently to migraine headaches. Migraine headaches, as you know, usually a unilateral throbbing pain associated with nausea, sometimes vomiting, aversion to bright light, sounds and much more common in women of childbearing age, because of the link with female hormones. Cluster headaches is often unilateral as well, often located around the eye area and can be associated with what we refer to as autonomic features. And that can be a droopy eyelid on the same side of the pain, there can be tearing of the eye, there can be congestion in the nose, there can be a redness in the eye. And that pain can go on anywhere from 15 minutes up to nearly an hour and a half, 2 hours, 3 hours. And it’s a very severe pain, a very boring, severe pain. You know, it’s colloquially called suicide headache because that’s the severity of the pain it is. And patients can sometimes feel as though they need to hit their head against the wall to relieve the pain. That’s how bad it is. So a very different characteristic to migraine type headaches and less common in women. We don’t see the same hormonal association with cluster headaches that we see with migraine patients. So typically with migraine patients, we’d notice that it could worsen in the first trimester because estrogen levels are still a little low and they’re feeling sick and they’re not eating as well. But we’d notice migraine patients would get better in their second or third trimester as their estrogen levels rise. They can almost have what they call a migraine holiday during that time and they feel the best that they’ve ever been. But cluster headaches, we don’t see that. And if cluster is bad before they get pregnant, then they’ll remain so during their pregnancy. They won’t necessarily see an improvement. And management can therefore raise an issue because some of the drugs that are used, we have to be a little careful of. Cluster headaches are often aborted by the use of high dose oxygen and that’s fine to take and they can continue to use their oxygen that they’ve got at home, they often have cylinders at home to try and abort their attacks. They use sumatriptan, often subcutaneous preparations, that’s under the skin. And the reason they use those is because the attacks are a lot shorter than migraines you need it to act a lot quicker and they can continue, as I’ve already alluded to, Sumatriptan is safe and they can continue to take the sumatriptan during pregnancy. And the other intervention that I particularly find useful that we use in other headache disorders as well are the greater occipital nerve blocks. And I know you’ve mentioned these previously on your podcast as well, and these nerve blocks are essentially subcutaneous, so under the skin, injections at the back of the head. We can do the right side or the left side, both, bilateral ones are also done. And we use a combination of local anaesthetic and steroid. Sometimes you use steroids, but mostly we do give that. And we find that the combination of the two can just sort of break a cycle of pain and reset the system, essentially. Make the primary headache actually a bit more treatable by breaking the cycle like a circuit breaker. And particularly in pregnancy this is quite a good intervention. And the reason for that is because it’s a local injection, it’s been injected under the skin and therefore there is very little, if any, in the way of absorption into the mother’s bloodstream and therefore very little chance that much is going to get to the baby. And for many women, that just sits a little better with them. So they’re not taking anything orally. And the few clusters that I’ve had in the last year or so, I’ve managed with regular greater occipital nerve blocks performed every trimester. So with a three month interval. And that’s worked tremendously well.


Dr. Katy Munro [00:25:29] Yes, I’m aware a lot of cluster headache patients find those greater occipital nerve blocks are really, really helpful. And that brings me on a little bit to talking about COVID, because one of the impacts for our patients with COVID and the lockdown is that those patients who are relying on injection therapies like Botox or greater occipital nerve blocks haven’t been able to access them very easily. You know, have you seen many pregnant women who’ve got COVID 19? Has it made their migraines worse?


Dr. Pooja Dassan [00:25:58] Yes, COVID has changed things. For a start, many of my migraine patients now that I am seeing whilst they’re pregnant in the antenatal clinic, we’re performing these consultations on the telephone with them, because we’re trying to reduce their footfall to the hospital and that’s certainly something very new in many ways. It’s suiting them. A lot of them would prefer not to come in and they don’t have to take time off work. So certainly the footfall to hospital has stopped. However, it’s an important message to, I guess, go out to your listeners that pregnant women should attend if they’re asked to do so. So ultrasound scans, particularly those that are having regular growth scans every fortnight or so, should feel that they can attend and should be encouraged to attend for those and their care should not be compromised as a result of COVID. And that was clear on all the guidance that’s been published from the Royal College of Obstetricians and Gynaecologists since the pandemic started. And they’ve also been quite clear that pregnancy does not put patients at a significant increased risk. And most women would just have a very mild to moderate infection with COVID 19. For the reasons I’ve already alluded to, being that pregnancy is a slight immunosuppressed state, and I stress slight, pregnant women have been classified being sort of clinically vulnerable, but theoretically so really and as I say, majority would really do just as they would outside of pregnancy should they contract the infection. In terms of its effect on our migraine patients, if we feel that they would benefit from coming in and having a block during their pregnancy, that is still being arranged on an individual patient basis and we’re not stopping doing that if that’s the only way we can manage the mother’s pain during pregnancy.


Dr. Katy Munro [00:27:37] The other thing about COVID 19 now, of course, is the vaccination programme rolling out, isn’t it? And I was reading some guidance about this the other day and saying that it’s absolutely fine for pregnant women to have the vaccination.


Dr. Pooja Dassan [00:27:53] That’s correct. So initially, as is the case with everything, when new drugs come out, when new vaccines come out, pregnant women are not included in clinical trials of drugs. And therefore, the advice always is until more data is collected and registry data that we’ve already alluded to, pregnancy registry data, that pregnant women should not receive this medicine. And the same happened when this vaccine came out. And of course, pregnant women get non-live vaccines all the time. The influenza, that’s the flu vaccine, is offered to all pregnant women, as is the whooping cough vaccine. And it was really felt particularly by the RCOG, the Royal College of Obstetricians and Gynaecologists, that why should the COVID 19 vaccine be any different to this? And as a result of this, on December 30th, this was reviewed and an updated outcome was put out which suggested that certainly women that have any other underlying medical conditions so they are clinically highly vulnerable would certainly be offered it and there would be a discourse and a discussion and if they agreed to take it, they would be offered it. Certainly, breastfeeding was another indication initially, that if you were breastfeeding, you wouldn’t have the vaccine. But again, that has also been changed and those guidances has also been updated.


Dr. Katy Munro [00:29:08] Yes, I think that’s very reassuring because I was hearing that people who are breastfeeding were feeling that we’re going to have to choose, shall I stop breastfeeding so that I can have the vaccination or shall I have the vaccination and not tell the truth about the breastfeeding? You know, it was quite a difficult one. So it is quite reassuring that that is very clear guidance now, isn’t it?


Dr. Pooja Dassan [00:29:31] It is. And certainly with the breastfeeding, you and I know this, we can’t say enough, the benefits of breastfeeding are incredibly evidence based and not only from health outcomes, but also from the bonding that comes between the mother and the baby. So for various reasons, it should be stressed that, you know, it is safe and women should be encouraged to get the vaccine and to breastfeed.


Dr. Katy Munro [00:29:55] I completely agree. I’m a big fan and I’m very, very keen to encourage people, but also aware that some women just simply don’t manage to breastfeed and I think one of the impacts of the COVID lockdown has been that the breastfeeding support for mothers hasn’t been quite as good as we might sometimes hope. Let’s hope with the vaccine rolling out, we’ll get a bit more normal life coming back. Staying on breastfeeding and just talking about medication again. Anything specifically about headaches in the breastfeeding postpartum period that is different from what we’ve discussed already?


Dr. Pooja Dassan [00:30:31] Yeah, that’s a brilliant question. And so particularly with migraines, we talked about there being a very close relationship with estrogen levels and we talked about how the migraines would often improve by the second and third trimester. But what happens sadly then, is that after the mother gives birth, the estrogen levels will start to drop and that can result by day three to day six with quite a crashing headache. And that’s not helped by, of course, sleep deprivation, missed meals and the stress that comes with having a newborn at home. So all of that can result in a really quite sick, poorly mother which is quite tough. So again, it’s really important that we inform our patients that there are options for them, that there are things they can take and they don’t just have to grin and bear it. And certainly again, we’ll go back to paracetamol. Of course it is safe, but it probably won’t help much with the acute migraine attack. Non-steroidals  are fine to take again in the postpartum period when they’re breastfeeding. There’s not an issue with that. The aspirin, as I mentioned, should be avoided. It can lead to this condition called Reyes Syndrome in the baby. And triptans, very little triptan is actually- it’s got very poor, what we call, oral bioavailability so very little of it will get through to the baby and secrete into breast milk. And the general rule of thumb for doctors who are treating these patients is that if there is evidence that the drug is secreted less than 10% of the maternal dose into breast milk, that it is a safe drug for the baby and shouldn’t cause any harm.


Dr. Katy Munro [00:32:02] That’s very reassuring, I think. It is such a time of change when you first have a new baby, isn’t it? My own daughter has gone through this through the lockdown. So we have some personal experience of a lifestyle being turned upside down. Very little sleep, quite a bit of stress and physiological changes and as you said, eating at different times. And so we always at the centre, we’re always banging on about the kind of keeping that regularity of routine and lifestyle as much as you possibly can if you’re trying to prevent your migraines kicking off. But I did read somewhere that there was a paper that showed that breastfeeding was slightly protective against the migraines returning so another good reason.


Dr. Pooja Dassan [00:32:41] That’s absolutely right. Yes.


Dr. Katy Munro [00:32:43] That’s very nice to know. So I wanted to ask you about Hughes syndrome in particular, because this is something that patients of ours sometimes ask us to do a bit of discussion about on the podcast. Can you say something about Hughes syndrome?


Dr. Pooja Dassan [00:32:57] Yes, of course. So Hughes syndrome or other people may know of it is Antiphospholipid syndrome is an autoimmune condition. And what that means is essentially that our bodies, which normally make antibodies to fight off infections such as bacteria or viruses. In this scenario, and there are many other conditions that are also autoimmune, antibodies are made against normal tissue and the concern with regards to the Antiphospholipid syndrome and the antibodies that are made in that and neurological manifestations is usually in the way of making, again, the blood extra sticky and clotty. And I’ve had patients who have had the diagnosis of Antiphospholipid syndrome and get recurrent mini stroke like episodes. I’ve looked after one a few years back and this particular patient was having recurrent episodes where she felt her vision would disappear in one eye. Typically, we call that an amaurosis fugax where there’s almost like a curtain coming down in one eye. And that’s how she had presented and been diagnosed with this Antiphospholipid syndrome when we checked to see whether her blood was extra clotty. And what sort of risk can that pose if she were to choose to become pregnant? Well, I’ve already explained that pregnancy is a procoagulant state as well. It makes blood extra clotty. So we would be concerned that she would be at increased risk of further clots because she already has this predisposition with this condition. And many of these women, if they’ve already had clots before they become pregnant, will be on blood thinning medicines. And a lot of women may worry about what’s going to happen about that. Certainly if they’re taking drugs such as warfarin, a common drug used for blood thinning, that would be stopped in pregnancy because warfarin can pass the placenta and cause problems and malformations in the foetus. So that would always be stopped and patients are often switched because we can’t leave mum off anticoagulation of course, and they would often be switched to heparin. And this is an alternative blood thinning agent, often given as injections under the skin and the pregnant mother would be taught how to inject herself throughout her pregnancy. And we would monitor often in pregnancy with blood tests to check that the heparin was working well by checking her bloods to ensure that’s the case. And we would normally continue the heparin injections like that on a daily basis until mum gave birth. If she hadn’t been on warfarin beforehand and the heparin injections were just started prophylactically during the pregnancy at a lower dose, then you’d often continue that for at least six weeks after Mum has given birth, again, because pregnancy keeps your blood being extra clotty for at least six weeks later.


Dr. Katy Munro [00:35:33] So I think the reason we got asked about that is it’s a rare cause of headaches. So another secondary headache that people need to be aware of. So if you were seeing somebody with migraine type symptoms or what you described as more of- might be mistaken for aura symptom, what sort of tests are available to to look for Hughes syndrome or Antiphospholipid syndrome.


Dr. Pooja Dassan [00:35:56] So again from the manifestation being of a new onset headache or a new onset aura symptom in someone that has already got Antiphospholipid or you’re concerned that they could have, there are blood tests that can be done in the first instance, but if you are worried that this is Antiphospholipid syndrome causing a clot in the head as a presentation of headache or a new aura symptom, then that patient should present straightaway to A&E and would have an urgent scan performed at that time. And then if a clot was diagnosed then all the blood tests would be performed at that time to see whether the blood is extra clotty. Some of those blood tests are not that reliable in pregnancy, those pro-clotting blood tests that we do. And therefore if they did have a clot and we couldn’t quite get the diagnosis then, they would then have those bloods repeated again after they have given birth. And it may be that the diagnosis comes to light then.


Dr. Katy Munro [00:36:46] Is it something that runs in families?


Dr. Pooja Dassan [00:36:48] Yes, it can do, absolutely. And that’s something that certainly if your parent has had it, you would be at increased risk of it.


Dr. Katy Munro [00:36:55] So if anybody is aware that there’s something that’s caused repeated clots in a family member, that it would be worth them getting that checked out if they’re planning a pregnancy and just to go talk to somebody.


Dr. Pooja Dassan [00:37:05] Yes. Absolutely right. The other presentation of Antiphospholipid, and that is relevant, is that patients that can present with repeat miscarriages and if there is a history of repeat miscarriages, these blood tests are done at that point as well to look for it.


Dr. Katy Munro [00:37:19] That’s really interesting. Thank you for that. That’s something we’ve been wondering about. So I was just wondering now I’m aware that patients like to go and look things up and there’s a lot of information out there. We’ve been recommending that the BUMPS website is quite good for safety of medicines in pregnancy. Are there any other particular sources that you direct people to?


Dr. Pooja Dassan [00:37:41] Yeah, I direct them mainly to the BUMPS websites and actually the UKTIS website, which is the equivalent for doctors, is very good and gives us very good information about drug therapy and its safety in pregnancy and breastfeeding. The NHS websites with regards to pregnancy and any of the conditions, whether that’s migraine or epilepsy, MS all the other stuff that I see in my clinic, I often guide them towards that as well. And then lastly, in terms of migraines, I guess it’s important to also direct them to information with regards to lifestyle issues, which are very important for them to continue to institute during the pregnancy just like they normally would outside of pregnancy. And certainly Katy, you’ll be aware of many resources available for this as well. But certainly the Migraine Trust website has lots of good information as well. I thought this might be a good opportunity just to recap on those as well, which I know you’ve covered extensively in previous podcasts, but it’s so important just to reiterate those and to mention firstly water, and that’s important in pregnancy. I’ve already alluded to the fact that low blood pressure can be an issue for a lot of women in pregnancy, particularly if they’re taking propranolol as well. And then of course, poor hydration and migraines are quite closely associated. So we often ask women to keep up their hydration. Now, with pregnant women, I always say, try not to drink lots of water before you go to bed. And they already have lots of issues with waking up several times at night to pass urine and that doesn’t help things. So make sure that your water intake is earlier on in the day, otherwise you’re not going to be helping yourself. Secondly, the caffeine. Now, most women have already stopped taking caffeine once they get pregnant and they’ve already switched to decaf, which is brilliant. But those that haven’t, we advise them that daily lot chronic caffeine use can make migraines worse. Many people ask me, but there’s often caffeine in the medicines that we buy. And of course that is the case. There’s a lot of medicines which have a analgesic, so codeine or paracetamol, and then they are paired with caffeine because acutely a little bit of caffeine thrown in with the analgesic can enhance the analgesics use and its efficacy so it’s much better. But actually it’s not particularly helpful if you’re taking vast amounts of it every day. And then sleep. Sleep can be a major issue for pregnant women, especially as they get into the third trimester and they’re ever so uncomfortable. But we know that poor sleep can lead to very poor management of migraines, and they can get a lot worse, particularly in the postpartum period as well. So we continue to talk about the usual measures that they should take. And as you said, the routine is the most important. That’s trying to get to bed. How can you do that with a newborn? But trying to get bed at the same time and waking up at the same time and trying to give yourself an opportunity to sleep at least 8 hours. I mean, you can certainly do that in the antenatal period, but that’s going to get a lot more tough in the postnatal period, which is why I always say don’t be a martyr in the postnatal period and get all the help you can, particularly if you know those migraines are just going to come back as severe as ever. And I think prioritising sleep and just making sure, you know, you’re not just wearing your 4 hours sleep with a badge of honour, as many people do in our 21st century world, I think is incredibly important.


Dr. Katy Munro [00:40:59] I think when we’re talking to people about lifestyle, I always like saying, you know, you have to be realistic about what you can control. And when you have a small squalling baby, you know, breastfeeding in the night and all of the disturbances that goes with, it just isn’t necessarily practical, but it’s working towards an ideal solution best you can with the limitations of what else is going on in your life.


Dr. Pooja Dassan [00:41:23] No, that’s right. And if you have a sleep deficit and you only got 4 hours the night before because baby was up, you’re going to have to try and prioritise catching up and, you know, be kind to yourself. Give yourself the opportunity to do that.


Dr. Katy Munro [00:41:35] Yeah, definitely. Well, that’s brilliant. Was there any other points that we should have covered, Pooja, that I haven’t asked you or you were wanting to raise?


Dr. Pooja Dassan [00:41:44] I think we pretty much covered most of it, actually. I can’t think of anything else. I guess the only other thing, Katy, that is becoming an issue and this isn’t entirely just related to migraines in pregnancy, but is the mental health of women at the moment, particularly in pregnancy as well. Now many are at home on their own with just their partner in the family. People aren’t getting out and if they had a pre-existing diagnosis of a mental health disorder such as depression or anxiety, we’ve heard so much on the news about it as well and it’s also been published in the journals, that there has been a spike in the presentations of exacerbations of both depression and anxiety. And that’s something that certainly obstetricians and midwives are very vigilant of in the perinatal period as well as the postnatal period. And certainly if you’ve had a pre-existing history of mental health issues, then you are at increased risk of developing postnatal depression, which can really be quite upsetting. So what we’re recommending is that, and certainly obstetricians are doing this, is just that the general practitioners in the antenatal clinics, the midwives are asking patients each time they come in or if there’s any interaction even on the phone if they’ve had any concerning symptoms. So for your listeners that would include, you know, negative thoughts, low mood, loss of appetite, a significant disruption in sleep and a lack of enjoyment of things that they normally would, and particularly in these current times with the pandemic and how difficult it is, if those symptoms have become worse during pregnancy, then to alert your general practitioner or your antenatal clinic about this. Patients can also self-refer to local IAPT services and there’s a local number for each borough, certainly in London, which they can refer themselves to. And you don’t require a doctor to do that for you and you can speak to someone about this.


Dr. Katy Munro [00:43:48] I think that’s so important actually, because, we know that people who suffer with migraine have a higher risk of having depression. And I certainly see many, many people who have anxiety as well because they’re anxious about will they get an attack and how is the attack going to affect their lives going forward, how they’re going to deal with it? So, yeah, I completely agree with you. We did an episode a while ago about migraine and mental health, but I think it’s especially relevant at this time. And even though it’s so difficult with the lockdown, I think just that sense of connecting with people is helpful, isn’t it, albeit it may be on Zoom and we may have to be 2D to everybody, but there is going to be a light at the end of the tunnel. It just seems as if it’s this very small glimmer at the moment. But hopefully with the vaccination programme rolling out and the measures that have been taken, we’ll get back to being able to see each other.


Dr. Pooja Dassan [00:44:44] No, I think so. Absolutely right. I think the prediction is that, you know, the tide is going to slowly start turning and within two weeks we should start noticing a difference. And all our sacrifices that we’ve all made in this last year will be worth it, I hope, as you say, there is that little light and I’m holding onto that as well.


Dr. Katy Munro [00:45:06] Yes, me too. Well, thank you so much, Pooja. This has been an absolutely brilliant episode. I know people are going to get an awful lot of really useful information. So thank you very much once again.


Dr. Pooja Dassan [00:45:19] It’s a pleasure. Thank you for inviting me, Katy.


[00:45:22] You’ve been listening to the Heads Up podcast. If you want more information or have any comments, email us on info@NationalMigraineCentre.org.uk. Till next time.


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This transcript is based on a past episode of the Heads Up podcast and reflects information available at the time of broadcast – some facts may have changed or new treatments become available since.

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