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AAPM Comments on AHRQ Key Questions for Systematic Review on Management of Primary Headaches in Pregnancy

Comments from the American Academy of Pain Medicine

The American Academy of Pain Medicine thanks the Agency for the opportunity to comment on The Evidence-based Practice Center Program at the Agency for Healthcare Research and Quality key questions for the systematic review on Management of Primary Headaches in Pregnancy.

The questions listed here are very well thought out, however we do want to make some comments that may help the direction of the review.

  1. What are the harms or comparative harms of treatments for migraine or other headaches during pregnancy?
  2. What are the harms comparative harms of interventions to prevent migraine during pregnancy?
  3. What is the effectiveness or comparative effectiveness of treatment for migraine for women during pregnancy?
  4. What is the effectiveness or comparative effectiveness of interventions to prevent migraines for women during pregnancy?

In looking at the groups and questions that are fleshed out in the document, it appears that you are clumping pregnant, post-partum, and nursing migraines into the same cohort. This may not be factually correct. In general, women's headaches present very differently during these time periods and interventions may also be different, thus we would encourage separating these groups.

We strongly believe that the management of migraines needs to be multidisciplinary. In looking at the interventions you have delineated, we would suggest a more inclusive expansion of the interventions for migraine reflecting the multidisciplinary nature of migraine treatment. Starting with lifestyle, we suggest including diet, hydration, sleep, and exercise. We would also encourage including behavioral strategies including therapy and support groups as well as complementary medicine such as vitamins, herbs, and acupuncture. We also suggest consideration be given to inclusion of procedural strategies such as greater occipital nerve blocks, trigger point injections, sphenopalantine ganglion blocks, and non-invasive neuromodulation devices (Cefaly, TMS, Gammacore). Regarding medical interventions, physicians differentiate medications for migraine into two distinct groups: preventives and rescue or abortive medications. Breaking the medications into distinct groups will help in the analysis. It would also be helpful to provide some clear guidance on what pharmacologic interventions are the safest and which are strongly contraindicated. Again, these indications will vary in pregnancy, in post-partum and in breastfeeding.

Thank you for this opportunity and please feel free to contact us if we can be of any further assistance.

About AAPM

The American Academy of Pain Medicine is the premier medical association for pain clinicians and their treatment teams with some 2,000 members. Now in its 36th year of service, the Academy's mission is to advance and promote the full spectrum of multidisciplinary pain care, education, advocacy, and research to improve function and quality of life for people in pain. Information is available on the Academy's website at painmed.org.

Approved by the AAPM Executive Committee on April 11, 2019

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