🩺 How We Decide to Image a Pregnant Patient with Headache: A Clinical Reflection Anchored in Judgment, Safety, and Respect

🔍 Do We Image Every Headache in Pregnancy?

No.
But Here’s When We Must.

The question of when to order neuroimaging in a pregnant patient with a headache isn’t answered by protocol alone. It requires clinical judgment, humility about our limits, and deep listening to the patient.
As physicians, we balance risk, probability, and pattern recognition. But we also rely on what doesn’t fit—the subtle clinical dissonance that tells us that something is wrong here.

Here’s how I approach it:

🧠 1. How reliable is my neurological exam?

If I have any doubt—if the patient seems “off,” if her symptoms don’t match her physical findings, or if she’s too altered to examine—I bring in neurology. However, many hospitals don’t have on-site neurologists. In those cases, I am the best neurologist she’s going to get—and that means taking that role seriously, not dismissively.

🔁 2. If she’s back for the same complaint, everything changes.

A return visit for the same symptom—especially a headache—is a clinical warning siren. Most people avoid the ER like the DMV or the IRS. So if they’re here twice, we have to ask: What didn’t we catch the first time? What are we missing? That second visit demands a fundamentally different response, not repetition.

💉 3. The “headache cocktail” and the litmus test of improvement

I typically start with a first-line headache cocktail—fluids, antiemetics, acetaminophen, maybe caffeine, sometimes magnesium. Then I assess.

If the headache improves, great. But if I’ve tried two medication regimens and the headache persists? That’s when imaging becomes mandatory. I don’t send someone home with an unresolved, unexplained, intractable headache—especially in pregnancy.

🚨 4. Can I safely discharge this patient?

If I’m considering discharge, I must answer:

• Can I confidently explain the cause of her headache?

• Has it improved significantly?

• Can she safely manage at home without escalating risk?

If I’ve tried treatment and her pain remains severe or unexplained, I need a CT or MRI to rule out hemorrhage, CVST, or mass effect. In pregnancy, this is not over-testing. Overall, this is fairly rare; however, in a large academic institution, you will likely see a handful of patients with this diagnosis each year.

🗣️ 5. Ask her: “Do you feel safe going home?”

My final check-in before discharge is always:

“Do you feel safe going home?”

“Do you feel comfortable with this plan?”

If her answer is no—or if she hesitates—I listen. Because she knows her body better than I do. And sometimes what saves lives isn’t another test—it’s making space for the patient to say: “Doctor, something still isn’t right.”

📚 Clinical Case: When Judgment Saved a Life

Not long ago, a pregnant patient came to me with recurrent, unexplained abdominal pain. She had been seen by multiple providers. Labs were normal. Imaging was inconclusive. She wasn’t hypertensive or tachycardic. But her pain lingered—and something didn’t add up.

I scanned everything—uterus, liver, kidneys. All normal. Yet, her pain persisted. When I asked her:

“Are you improving? Do you feel okay going home?”

She said no. And that was all I needed. I transferred her to a higher level of care.

The diagnosis? Pheochromocytoma.

A rare adrenal tumor causing episodic hypertension and pain. Not on my radar. Not on the differential. Not visible on our initial CT scan. But we found it—because we listened.

👩🏾‍⚕️ What This Means for Cases Like Adriana Smith

Adriana Smith presented twice with a severe headache while pregnant. She was sent home—no imaging, no escalation, no investigation.

This should never have happened.

Had any one of the above principles been followed:

• A persistent headache despite treatment

• A return visit for the same complaint

• A worsening sense of unease

• A patient simply saying: “Something is wrong” then someone would have said: We need a CT scan.

This isn’t just about protocols. It’s about attunement.

🧭 Final Word: When in Doubt, Stay Curious.

Medicine is more than science. It’s instinct, pattern recognition, and humility.

Sometimes the only thing that saves a life is refusing to dismiss what you don’t understand.

And when a patient’s still suffering—and says, “I’m not okay with this plan”—that’s not the end of the visit. That’s the beginning of the most important one.