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Headache patterns for both primary and secondary headaches are often modified in women during pregnancy. Although approximately two thirds of women with migraines experience headache improvement during pregnancy; women who continue to suffer from migraine or other headaches during pregnancy need effective clinical care to include appropriate diagnostic studies, counseling about expectations during pregnancy and lactation, and modifications in therapeutic regimens to minimize risk to the fetus and nursing baby. This review describes the epidemiology of headache during pregnancy and lactation, to include both effects of these conditions on headache activity and possible concerns about how a maternal headache diagnosis may influence the course and outcome of pregnancy. Although restrictions in diagnostic testing and medication interventions are often necessary during pregnancy and breastfeeding, this review describes evaluation and management strategies that provide effective clinical care while minimizing risk to the developing baby.

Migraine is recognized as a primarily neural condition. Changes in neural physiology have been consistently identified in migraineurs. Numerous studies are available that evaluate physical and functional differences between migraineurs and headache-free controls. The most prominent neuroimaging findings reported in migraine sufferers have been white matter changes. However, physical changes on neuroimaging have not been clearly correlated with functional impairment in migraineurs. The current literature addressing the neuropsychologic consequences of migraine has been far from conclusive, and reports of cognitive testing in adult migraineurs and controls has yielded inconsistent results. Neuropsychologic testing suggests that there may be some subtle but possibly significant changes in cognition that occur both during and between migraine episodes. A finding emerging with some consistency is that migraine patients with aura experience more neuropsychologic deficits than migraine patients without aura. The few studies that assess nonmigraine headache suggest that physical changes may not be unique to migraine, although neuropsychologic changes do appear to be limited to migraineurs. An examination of the unmet needs and priorities for future research addressing this important topic is provided.

Recently revised guidelines from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) call for an increased awareness of the impact of chronic pain and recommend that physicians assess and treat pain complaints seriously. Although significant and persistent chronic pain is a common reason for primary care visits, the incidence of psychologic distress and personality disorder in patients with chronic pain often makes this population a difficult one for physicians and staff to treat. This discussion offers practical tips for managing patients with chronic pain and reducing staff burnout. The author also dispels various myths about chronic pain and focuses on the effective management of its comorbidities.