Joining us for the first time is Dr. Naomi Feuer, a neurologist who practices just a few blocks from MFMA. She sees many patients, both pregnant and not, for sudden onset headaches and migraines, helping find an accurate treatment plan, even if that means simply waiting to deliver to relieve headache pain or secondary symptoms like carpal tunnel. The vast majority of patients get positive results from the imaging and other tests she performs, and in the rare case it’s a more serious condition, you’re in good hands with a neurologist.
“Headaches in Pregnancy” – with Dr. Naomi Feuer
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Dr. Fox: Welcome to today’s episode of Healthful Woman, a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist practicing in New York City. At Healthful Woman, I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
Dr. Naomi Feuer, thank you.
Dr. Feuer: How are you?
Dr. Fox: I’m great. Thank you for joining the podcast. This is awesome. I love it.
Dr. Feuer: I’m so excited to be here.
Dr. Fox: So, we’ve known each other a while personally, professionally, and then we were seated at the same table at a wedding. And I’m like, “Dude, why have you not been on my podcast?” And you’re like, “Why have you not invited me?” And so here we are, we’re together.
Dr. Feuer: Yeah, so we finally made it happen. I’m really, really excited. This is great. Now, you are a neurologist. You are an assistant clinical professor of neurology at Cornell just across a few blocks from where I am. How’s that going? How are you enjoying neurology in New York City?
Dr. Feuer: You know what? I love practicing neurology. I, kind of, always viewed neurology as a little bit of a puzzle, you know? I didn’t want to be, you know, a jack of all trades. I wanted to hyperfocus on one, you know, organ system and, you know, try to figure out, take all the clues and try to figure out what’s going on with the patient. So, it’s a lot of fun. It’s a lot of fun. It’s interesting. It’s challenging at times, but I enjoy every minute of it.
Dr. Fox: Yeah, you know, so I grew up in the home of a neurologist. My dad’s a neurologist. He’s been on the podcast.
Dr. Feuer: That’s right, that’s right.
Dr. Fox: And it was always, sort of, the stereotype, which is probably true, that neurologists ironically are very cerebral. Like, they like to think about things. Like, the problems are complicated, you know?
Dr. Feuer: Yes, yes, we like to think and overthink and analyze. So, you know, it goes well with certain personality types.
Dr. Fox: At what point in medical school did you realize that you were just, you know, a neurologist waiting to be chiseled out of that block of ice?
Dr. Feuer: Funny, you know, I think around my third-year rotation when I started at neurology. And I was just fascinated by the patient’s presentations and the explanations for them and, you know, linking the pathology that we could see whether, you know, radiographically or otherwise with the patient’s clinical presentation.
I remember a patient came in looking like she had a stroke, and it was only a UTI. And I thought like, “How amazing is that, the things that can affect the brain?” You know, from something so severe, you can have the same presentation as something so mild. So, you know, I just was really taken.
Dr. Fox: Well, now in your current practice, what would you say is your, sort of, breakdown of patients or, sort of, things that you’re diagnosing and treating? Are you doing more general neurology? Are you more specialized? You know, maybe as a percentage, how is your day or your week broken down would you say?
Dr. Feuer: Absolutely. So, I’m a generalist in general, and I sub-specialize in neuromuscular disorders. I did a fellowship in that at Cornell. So, that’s, sort of, my area of expertise, but I treat all sorts of issues, including headaches. I do a lot of spine work, a lot of back pain. I work closely with neurosurgeons. People will come into my office with different clinical presentations or complaints of, you know, they’re numb or their head hurts or they feel they’ve lost some dexterity in their hands and they’re not sure why. And it is up to us together to, kind of, figure it out.
And the diagnostic algorithm is always very interesting and, you know, treatment options also. You know, at a certain point, medicine transitions to an art more than a science, and we, kind of, have to come up with the best formulation to maximize and optimize the patient.
Dr. Fox: Yeah, and would you say, as a general neurologist, are most people finding you just, sort of, on their own, meaning, “Hey, I have headaches. I have neurologic symptoms. I have a condition. I’m going to find a neurologist, you know? I’ll find someone at a world-class institution like Cornell,” and they find you, or are they referred to you by another doctor? Let’s say, you know, a general practitioner, or internist, or surgeon, or whoever says, “Hey, you know what? This problem is, sort of, beyond my scope. See a neurologist, see this neurologist.” How would you say it’s broken down? I’m always curious how people find us doctors.
Dr. Feuer: Yes, it’s a good question. I’d say, for me, majority of my patients come in through referrals from their internists or surgeons, you know, where they have very, very detail-oriented internists and, you know, when they had to go for their annual physical, the patient said, “A funny thing happened to me this summer. You know, I had numbness in my arm for an hour, but it went away and I’m better.” But, you know, we don’t want to leave anything to chance, and we want explanations for what goes on in our body. So, I will get a lot of referrals from internal medicine doctors, whereas I think the patient themselves wouldn’t have otherwise, taking the initiative.
And then I have patients who self-refer, you know, whether it’s Google, or their friends, or word of mouth, you know, where they just say, “I want to get in and I want to see someone,” because they’re worried. The internet also has played a huge role in the neurology referrals, because unfortunately, you know, I get lots of patients coming in and, you know, they see a little twitch and they’re worried about ALS. We live, you know, with a lot of stress and pressure, and there are a lot of symptoms that can come on that are completely benign but can be worrisome especially to let, you know, patients about possible neurological disorders.
Dr. Fox: Yeah, it’s the same problem, you know, you and I had going to medical school. When you learn about all these, you know, diseases, you’re like, “Wait a second. I’m tired. I have leg pain. My back hurts. Oh, my God. Like, I’m dying.” And so now everyone has the glory of that because they could find it all on Google, and they can, you know, self-diagnose all these horrible conditions. It used to be limited to us doctors, but now everyone has that joy in life of thinking you have something horrible.
Dr. Feuer: Exactly, it’s true. I misdiagnosed myself with God knows how many diseases. None of them actually panned out, but, yeah, and then now unfortunately, I see people tortured. I mean, sometimes part of my plan is no Google, and I’ll say, I’m just like, “And you got to promise me, no Google, it will make your symptoms worse.” They can definitely exacerbate things.
Dr. Fox: Yeah, you have Google-itis, and you need to stop…
Dr. Feuer: Google-itis.
Dr. Fox: You need to get off Google.
Dr. Feuer: It’s rampant.
Dr. Fox: It’s rampant, and it’s spreading. It’s contagious.
Dr. Feuer: Contagious.
Dr. Fox: Now since we’re going to talk today about headaches and pregnancy, how often do you have the honor, privilege, and pleasure to see pregnant folks in your practice?
Dr. Feuer: I’d say it’s about 20%. I see quite a few.
Dr. Fox: That’s a lot.
Dr. Feuer: Yeah, I think, you know, we worry a lot about pregnant women, right, you know, because… I mean, I don’t have to tell you. It’s more than one life. So, it’s double the responsibility. And, you know, I think that when it comes to neurological issues, they can be very, very critical and severe sometimes during pregnancy, and then very benign. And it’s tough to make that call, and it’s tough to know what kind of diagnostic workup you want to do and how aggressive you want to be, whether it’s in treatment or imaging or, you know, all of that because, you know, in general, I like to think, in medicine, whether a patient is pregnant or not or postpartum or not, less is more except for when you’re really, really worried.
Dr. Fox: And when the pregnant women come to see you, again, is it predominantly people with chronic neurologic conditions who are also pregnant or are these women who are pregnant who have, like, a new symptom, again, like a headache or weakness or something like that?
Dr. Feuer: Yeah, that’s a good question. Typically it’s the latter. I’d say the patients who, you know, have seizure disorders or myasthenia gravis or multiple sclerosis, the pre-pregnancy counseling is outstanding. And, you know, we really have good protocols and good data on some things and, you know, guidelines that we follow as to when to stop certain medications, you know, what to expect for many of those chronic conditions. But it’s when the patients show up with something they’ve never had before that, you know, everyone can get a little bit uncomfortable.
Dr. Fox: Right, and I would imagine that headaches is probably, if not, the most common up there with one of the most common things that you’re going to be seeing for pregnant women.
Dr. Feuer: Absolutely. Headaches and lots of carpal tunnel syndrome actually.
Dr. Fox: Yeah, oh, my god. It’s horrible. I feel so bad. They come in with…they look like they’re going rollerblading with the wrist splints and there’s so much pain. It’s horrible.
Dr. Feuer: It’s so horrible and painful, yeah, but it’s a great diagnosis to have. I was going to say if you’re walking away from a neurologist with carpal tunnel syndrome, like, you know, you won.
Dr. Fox: Yeah, that’s a win. That’s a win.
Dr. Feuer: It’s a win, it’s a win.
Dr. Fox: It’s a win because your pain is going to go away after you deliver, so it’s a win. So, let’s talk about headaches in pregnancy but just, sort of, as a background. In terms of headaches in general, right, so obviously there’s going to be overlap between headaches and pregnancy and headaches in general, how do you think about headaches? When someone comes into your office who’s not pregnant, they come in and they’re like, “Hey, I’m healthy. I’m fine otherwise, but, man, I’m having all these headaches,” how do you evaluate them and, sort of, get them from point A to point B with a diagnosis?
Dr. Feuer: When a patient comes in with a nuanced head pain that they’ve never had before, non-pregnant patient, so for me personally, I tend to be very conservative. I always get diagnostic head imaging because, you know, nuanced head pain, while we presume this pain syndrome, it’s well reported. It’s quite prevalent, but, you know, we just want to make sure that we’re not being arrogant or missing anything or just saying, “Of course, you have classical migraines, and we’re just going to put you on this medicine and you’re going to feel all better.” I like to make sure that I can define, as best as possible, what I’m dealing with, you know? And, again, women in their 20s and 30s, which happens to be, you know, a time period when lots of women choose to have children, people will, you know…that’s the time when the migraines frequently begin in lifetime, especially for women. So, it’s important to target it and treat it.
And there’s this assumption that there’s tension-type headache, and there’s migraines. But what we’ve learned really is that all head pain is really along a continuum. You know, pain is mediated by the trigeminovascular system. And, you know, whatever is setting off the release of inflammatory mediators, whether it’s causing migraine symptoms such as, you know, half the head is pulsating, and there’s photosensitivity, and noise sensitivity, and nausea, and vomiting and, you know, just complete lethargy, you know, that would be a classical migraine. But then you have people with, if you dial those symptoms down by, you know, 50% and they have a dull ache and a little bit of fatigue and a little bit of something, we could say it’s tension. But we’re starting to think it’s all a variation of the same thing.
Dr. Fox: That’s really interesting. I didn’t realize that you are, sort of, nowadays blurring the lines between these types of headaches, because, you know, when you read about it and we learn about it, they always say, “All right, it’s either a migraine, or it’s a tension, or it’s a cluster, and, you know, this is this, and this is this, and this is this.” And they, sort of, present differently and treated differently. But you’re saying actually there’s a lot of overlap. It’s like a Venn diagram, so to speak, with those.
Dr. Feuer: So, there’s a lot of overlap. And in terms of treatment, there’s a lot of overlap because patients will frequently inquire and they’ll say, “Well, isn’t that a migraine medicine?” And I’ll have to explain to them, you know, that we only have so many tools in our arsenal and they’re all targeted, you know, to mediate head pain. You know, my goal is to make the patient comfortable and out of pain safely, so we use many of the migraine medications for tension-type headaches. We don’t really have treatment categories that we prefer. There are recommendations for different types, but at the end of the day, we want to use what’s safe and what works.
Dr. Fox: Yeah, and then when you said you get imaging, what does that typically mean for someone? Again, we’re talking about non-pregnant first. Is that usually an MRI, a CAT scan? What do you do?
Dr. Feuer: An MRI. And an MRI, of course, you know, there’s no radiation. It’s a magnet. And, you know, patients ask me that all the time. So, I generally never get head CTs. You know, I leave that for the emergency room.
Dr. Fox: And then what would you find on an MRI or what could you find on an MRI that, let’s say, you weren’t expecting but are on the list of things you just want to make sure isn’t? You know, what are we talking about here?
Dr. Feuer: So, the primary thing is a brain tumor. When somebody’s got a new onset headache, I want to make sure that they have no structural brain lesion. We also want to look for any kind of bleeding, any kind of bleeding aneurysm, or any kind of venous malformations. You know, any entanglement of the arteries and veins. And people can have clusters of little veins called…it’s called cavernoma where they’ll bleed out of that. And it will cause pain. And sometimes you can also see changes. You know, radiographically you can see changes when there’s pressure intracranially, high or low. And that can also play a role in head pain when there’s no structural lesion but there’s pressure changes within the cranium.
Dr. Fox: And when you’re evaluating them before this, you know, you’re listening to them, getting their story, asking them questions, doing, you know, an examination, and you do the imaging, are one of these things usually something that would come as, sort of, a surprise, meaning there’s nothing about their history and exam that indicated it or are usually already suspicious that it’s something different than a “classic head pain”?
Dr. Feuer: Yeah, typically, you know, there might be a cranial nerve abnormality such as, you know, one of the eyes aren’t moving in the direction that it should. We can sometimes see on eye examinations, papilledema, swelling of the optic nerves. Patients will have, you know, positional components to their headaches. So, there can be clues sometimes, you know, as to what the pathology, if there is a pathology, could be. But for the most part, that’s highly unusual. If the patient will have a structural lesion or a bleed that’s going to cause a clinical deficit that can be notable, they’ve probably come to medical attention at some point already.
Dr. Fox: Ah, understood. So, I guess, sort of, the takeaway point, I would say, is if you’re going to a neurologist and you have headaches and they examine you, they say, “You know, I think everyone’s okay. Let’s get some imaging to be sure,” the overwhelming likelihood is you’re going to go and get imaging that’s going to either find nothing, which is good, or find something that’s not so crazy. And you’re doing it just for those rare cases when there’s something that’s more concerning.
Dr. Feuer: Exactly. You know, there’s times where I’ll find things that I wish I never looked for like a Chiari malformation, which is controversial. That’s where the cerebellar tonsils are low lying in the head and can be associated with headaches, and the only fix for that is neurosurgical intervention, and it’s not a guaranteed fix. So, that’s a whole controversial topic. And you can see it’s certainly benign things that correlate with headache syndromes, but what I’m looking for and it’s always a good piece of information to have in a patient’s chart, but what we’re looking for really are anything that could be progressive and pathological or dangerous to the patient.
Dr. Fox: Okay, now, let’s focus now. You know, same situation but she’s pregnant, right? She comes to you, new onset headaches, didn’t have it before. Is there anything about your evaluation or your maybe differential diagnosis that is different simply because she’s pregnant versus non-pregnant?
Dr. Feuer: So, with pregnant women in particular, as you all know, early on, there’s symptoms of…you know, it’s very common to get headaches. You know, low basal headaches and those are typically benign and will go away after the first or maybe even second trimester. I could defer to you more on that.
Dr. Fox: Keep going, you’re doing great.
Dr. Feuer: But I think that, first of all, in a patient, I don’t feel reassured when a patient comes in with headaches, telling me that they had a history of migraine headaches, because migraine headaches typically will improve during pregnancy. So, it doesn’t make me think, “Oh, they’re just having more of the same.” It definitely raises a flag.
The one headache type that is sometimes considered to stay or, you know, worsens or associated with other pathologies is migraine with aura. So, migraine with aura can be worse during pregnancy. So, whether or not a patient has an aura, which is a neurological event that precedes the headaches such as, you know, colorful lights or you know, it’s typically a visual aura. You know, they see a rainbow of colors or flashing lights or zigzag lines, and those auras which is followed by a headache can be associated with worsening during pregnancy.
Dr. Fox: Okay. So, you’re seeing someone who’s pregnant. Do you still recommend the same imaging typically or are you less likely to do it or more likely to do it because she’s pregnant? So, if the patient has never had imaging before and their headaches are particularly bothersome and not in line with the classical headaches that might be seen more commonly during pregnancy, my first line would be to probably send them to an ophthalmologist and make sure that there isn’t any papilledema or swelling in their optic nerves. But I have a very low threshold for MRI. Very, very low. We always worry about things like strokes, which can be caused by hypertension. Then again, these things will be seen more in the later trimesters or postpartum period, you know, especially in patients with HELLP syndrome or, you know, other types of, you know, vascular issues during pregnancy.
We also worry about, you know, any hemorrhage into the pituitary as it grows during pregnancy. And especially if a patient complains of visual symptoms, the pituitary is right near the optic nerve. So, we really want to make sure that there isn’t any what we call pituitary apoplexy, or you know, hemorrhage into the pituitary because of its growth during pregnancy, because that will cause problems down the line.
Dr. Fox: Right. And then fortunately, MRI, like you said, since it’s not radiation, it’s just magnets, it is safe in pregnancy. It might be slightly annoying, but, you know, no different pregnant or non-pregnant. It’s just your head going, and it’s not your whole belly. But it is safe. It’s safe for her, it’s safe for the baby. So, it’s not a concern from our end medically to have an MRI, which is nice, so you can do that.
And, you know, I think that, you know, like you said, there are some things that are possibly going to happen in a pregnant woman or more likely to happen than someone who’s not. You know, things like, you know, blood clots or things like, you know, with the pituitary, as you said, or potentially even a stroke, because even though usually strokes are limited to people as they get older, in pregnancy, they can happen for other reasons. And with changes in their blood and a lot of changes, sometimes there’s probably red flags that go up for you in someone who’s 28 years old because she’s pregnant, that would really never go up at that age with who’s probably perfectly healthy.
Dr. Feuer: Exactly, exactly. And so, yeah. I mean, really the big warning signs for headache, you know, for something really dangerous, would be fever, swelling of the optic nerve, or any abnormal neurological findings on exam. Sometimes patients will report something called a thunderclap headache, which is like exactly what it sounds like. You know, a massive loud thunderclap in their head, which could be a sign of a hemorrhage. Sometimes if they say laying down, it’s better, or standing, it’s worse, that can be a sign of fluid changes that are leaking out of somewhere. So, we really want to be careful. We want to be careful with all patients who have these symptoms and especially pregnant patients with these symptoms.
Dr. Fox: Yeah, one of the hard things on our end is trying to figure out who to send to a neurologist because, like you said, a lot of pregnant women have headaches that are just from pregnancy and, you know, their nutrition changes, and their sleep changes, and their body changes, and their stress changes, and very common to get, sort of, that mild headache. And, you know, it’s hard for us to always know who to say, “All right, you’re perfectly fine. You know, it’s okay,” or to say, “Hey, try some of this medication,” and who to say, “Oh, you need to see a neurologist immediately.” So, you know, we have our ways that we do this, but what would you say for our listeners maybe who don’t see me, let’s say, and they’re out there and they’re having headaches on and off, how should they know if their doctor should be sending them to a neurologist or not for their headaches when they’re pregnant? What would you say is a good rule of thumb? Is it everybody or is it if they don’t respond to Tylenol or if they have certain symptoms? What would you prefer as the neurologist?
Dr. Feuer: As the neurologist, I would say that…
Dr. Fox: Everyone.
Dr. Feuer: Right, exactly. Come on in. We’ll check you out. We’ll line up the MRI. We’ll do pre-pregnancy MRI. But I was going to say that I think that, for most people, those early and dull headaches are okay and don’t need neuro referrals. And, you know, I’m a big believer that patients are…they know their body, and they know what feels wrong and what feels right, but forgetting the patient report, because that can be highly variable based on so many factors, if they’re vomiting, if they’re having crazy nausea, which is also a very common finding early on in pregnancy, but if they’re having tremendous nausea and vomiting with head pain that’s uncharacteristically worse than the typical pain you’re going to see, if they’re having any blurred vision or vision changes, if there’s a postural component to it. Whereas when I say postural component, they feel better lying down versus standing up, if they’ve developed high blood pressure during their pregnancy, I would say those would all be good reasons to see a neurologist.
Dr. Fox: Yeah, I mean it’s tough and in practice, it’s very common and we try to reassure women that it’s common. It’s probably fine. You’ll probably get better. But obviously not all of them that’s the case. And to try to weed out or triage who should go and who shouldn’t, I mean, typically, for me, if it’s something that’s mild, occasional, and gets better with Tylenol, that tends to be something I’m going to wait on. Obviously, if there’s something really unusual, other symptoms, like you said, “I’m going to send them to the neurologist immediately.”
And I think the tougher cases are sort of like what you’re saying. Someone is having pretty bad overall symptoms in the first trimester, a lot of nausea, a lot of vomiting, a lot of weakness, and they have a lot of headaches at the same time. It’s probably all the same thing. It’s probably all related, just a little more severe. And so probably those are the ones who I’ll hold off a little bit longer on sending to a neurologist even though their headaches are a little bit worse than typical. And sometimes you’re clued-in like, “Hey, if you have those moments when your nausea is better, maybe you took a medicine and your nausea is a little better for six hours or eight hours, are your headaches better at the same time? And if the answer is yes, then probably it’s just that.” But those I would say in my practice tend to be the toughest situations to figure out. Is this really bad headache something I should send to a neurologist or just sort of a worse case of the typical headache like nausea is worse.
Dr. Feuer: Absolutely. So, it’s hard for you guys, especially to gauge I think especially in somebody who had…I don’t think it should be determined based on their headache history. I think that, ironically, like I was saying, women with migraines tend to…their migraines typically improve during pregnancy. So, especially if it’s a migrainous-type headache as opposed to that low-grade, dull, just, “My head hurts a little bit but I can function through this just fine,” if it’s a more dramatic event or a spell, we could say, then I would definitely make the referral. But, again, I’m sure [inaudible 00:26:26] percentage of women largely are going to have headaches, a large percentage, then it’s going to be fine.
Dr. Fox: Yeah, and ultimately, the risk is low in sending someone to a neurologist. I mean, you’re going to get a good evaluation, a good history, someone is an expert in headaches. Maybe they’ll order an MRI, maybe they won’t, but it’s safe. It’s not dangerous. You know, worst case scenario, it’s annoying, whatever. You have to schedule it. And ultimately, assuming it just ends up being just the pain of it and trying to figure out the pain and treating it, at least you have a… And that’s where clearly you’re going to be much more adept at treating headaches than I would be, and so if it’s something that’s not really getting better with really simple measures, even if I know it’s not life-threatening, I’m going to want a neurologist to help anyways because you’re going to be better at it than I am just on the treatment end. So, I think it all ends up in the same place anyways. And if you get referred to a neurologist because of the headache, A, it does not mean there’s a big problem, and, B, okay, go, great. They’re going to be really helpful hopefully.
Dr. Feuer: And it’s just another set of eyes. It’s another evaluation. It’s someone else thinking of a differential diagnosis of what this could be and how to help someone safely navigate their pregnancy. It’s so individualized also per the patient, what number pregnancy this is, and how anxious they are, and that can play a large role as well. So, the evaluation certainly isn’t going to hurt them.
Dr. Fox: Yeah, how do you go about treating headaches during pregnancy? So, let’s assume either your evaluation by physical and history or you’ve got an MRI and you’re confident it’s not any of those sort of bad things and you’re just having straight-up headaches, what is your progression of treatment for someone in pregnancy?
Dr. Feuer: So, most of the headache medications are pretty much not considered safe, which is a problem. Obviously, Tylenol is the no-brainer, no pun intended.
Dr. Fox: The neurologist must love to say that.
Dr. Feuer: Yeah, it goes with the nerdy type. But, exactly, typically there are certain medications like propranolol is considered safe, or magnesium is considered safe, or CoQ10 is considered safe, or some of the SNRIs or tricyclics have some moderate safety. Reglan or any of the anti-nausea medications, which are commonly used, the Reglan and Zofran, those are considered safe. And Benadryl can sometimes take an edge off as well also just because of its sedating quality. But some of the calcium channel blockers can be used as well. But to be honest with you, I typically try to start with Tylenol and then doing a lot of, sort of, cognitive behavioral work to modify the pain and to manage the pain, because there’s so many question marks amongst some of our best headache medications. And some of them are absolutely contraindicated.
Dr. Fox: I find caffeine to be helpful.
Dr. Feuer: Caffeine? No, because my patients rebound from it. So, if they have one bad headache, yes, go for the cup of coffee and the Tylenol. It will be great. Some of it could be dehydration. Hydrate, rest. There’s lots of reasons. But I find that if the patient’s having…you know, so that would be for a one-time headache or if you know they’ve just got this really bad headache or if they got three bad headaches, but if they’re having daily headaches, I would veer away from caffeine because it can, you know, cause a secondary headache syndrome of rebound.
Dr. Fox: Oh, interesting. Okay, because I find sometimes pregnant women, before pregnancy, were having caffeine every day. And then they got pregnant and someone told them not to have caffeine every day. I don’t tell them that but, you know, Googled that or something, and then they’re like, “Man, I get headaches all the time,” I’m like, “Well, did you used to be caffeinated and now you’re not?” They’re like, “Yeah,” I was like, “Well, have your cup of coffee a day and see if that changes your life.” So they’re like, “Yeah, I’m back, I’m better.”
Dr. Feuer: And for something like that, I think though…but I would expect the withdrawal from caffeine to go away after a month or so. You know, they would re-equilibrate.
Dr. Fox: A month or so. I find out after a day.
Dr. Feuer: What’s going on? Yeah, I would definitely serve a cappuccino after that as well or recommend or prescribe one, but, yeah, I think that, after a certain point in time, if you’ve been without caffeine, I wouldn’t want to reintroduce it. But certainly if it’s in close proximity to when they were having their daily cup, which you guys are all okay with as far as I know.
Dr. Fox: Yeah. It’s interesting with a lot of the medications. There’s definitely hesitation to use them, but I think that we tend to be more, I don’t know, I guess liberal in allowing them than you guys are. I mean, you know, triptans which are used for migraines, you know, all right, if you can avoid it in the first trimester, maybe, but it’s not like they’re known to be harmful. And, you know, sometimes we’re okay with those and people say, “I’ve been getting these Botox injections in my scalp and my neck,” I’m like, “I’m fine with that,” and sometimes people aren’t. And I think it’s one of the reasons it’s nice in these situations if the obstetrician and the neurologists know each other, that they can talk and say, “All right. Now, listen, I think this is a thing that’s going to work. What do you think about this?” and then we can figure it out and talk to a patient like, “How much risk really is there?” and we can decide as a team what’s going to happen and what we should do.
Dr. Feuer: Yeah. And I agree. The multidisciplinary approach is probably the best one because, you know, we know headaches, but we don’t know, you know, obviously, OBGYN like you guys do. And like I said, you guys could determine in terms of…there’s a lot of gray in terms of safety. And to have a miserable pregnant patient isn’t healthy either. So, you really want to collaborate together, because the guidelines are very wishy-washy. They really are. So, if I have a patient who’s been getting Botox for years and years and years, and that’s been controlling their headaches and then they stopped it for pregnancy, I mean, it’s very reasonable that that’s why their headaches are back. And, you know, most obstetricians have been okay with it even though the guidelines are not clear and some of the patients are just, “I can’t live like this.”
It’s funny. I actually had one obstetrician who said my pregnant women are the most underserved patient population because everybody is afraid to do anything with them. And I think that it’s important to keep that in mind. I remember I never forgot it because they deserve treatment, you know?
Dr. Fox: Yeah, it’s totally true. And the fear that a lot of people have to treat pregnant women is understandable because they’re frequently venturing into, you know, sort of a world that they don’t have a lot of experience in, and are worried, and the stakes are very high obviously, and everyone’s worried about the baby. And that’s all true, and it’s legitimate, and it needs to be understood and cared about. But on the other hand, you also have this pregnant woman here who’s suffering from something and needs to be treated and we have to come together and figure that all out. And I think that with good interdisciplinary or multidisciplinary care, that can be achieved because frequently what happens is there’s just a lot of people saying, “Oh, you can’t do this,” and someone says, “You can do this.” And they’re like, “Well, what am I supposed to do? One doctor said yes and one doctor said no, and it’s very confusing.” It usually takes a conversation between the two, and they’ll sort it out, especially if it’s someone who does see pregnant women in their practice. The more experience, whether… It doesn’t have to be a neurologist. I mean, any other specialist has been seeing pregnant women, the more comfortable they’re going to be, and the more experience they’re going to have with what things are and aren’t gray versus black and white. And that’s hard. It takes a lot of experience to, sort of, get through that.
Dr. Feuer: Yes, 100%. And I think that, you know, it’s important to note. I mean, the pregnant patient is a patient. They need to be taken care of. And of course, the baby’s safety and well-being has to be of paramount importance. But, you know, they don’t have to be mutually exclusive. And, you know, there’s, sort of, this old conception I find that, you know, do nothing, do nothing, do nothing, you know, just suffer through it. And especially for my patients with headaches, it’s not good. It’s not good to be in chronic pain. It’s not good to be vomiting. I’ve seen patients with vitamin deficiencies from vomiting from headaches that have caused numbness, tingling, and other things, especially vitamin B1. I’ve seen deficiencies of thiamine from vomiting, and that can cause a lot of neuromuscular complications. So, we really need to make sure that we have things under control because the patient has to stay healthy in order to continue and have a healthy baby.
Dr. Fox: I could not have said it better myself, that’s perfect. Thank you so much for coming on the podcast and talking about headaches in general, and headaches in pregnancy. Again, very, very common, usually benign, and usually treatable but needs to be evaluated particularly if they’re severe, or if they’re recurring, or if there’s other symptoms, but fortunately, again, for most people and certainly for most pregnant women, they should be okay with a proper evaluation and treatment…
Dr. Feuer: Absolutely.
Dr. Fox: …by fine folks like you, Naomi. Thank you so much for being there, for being around, and for coming on the podcast to talk about it.
Dr. Feuer: My pleasure. Thank you so much for having me.
Dr. Fox: Thank you for listening to the Healthful Woman Podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at firstname.lastname@example.org. Have a great day.
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