What are the safest pharmacological treatments for migraine headaches during pregnancy?

From the Guidelines

Migraine Treatment During Pregnancy

Paracetamol is the safest and most recommended pharmacological treatment for migraine headaches during pregnancy, due to its relatively safe profile 1. The suggested dose is not specified, but it should be used as the first-line medication for acute treatment of migraine in pregnancy.

• NSAIDs can be used only during the second trimester, but with caution and under medical supervision 1.
• Triptans, such as sumatriptan, should be used only under the strict supervision of a specialist, as the safety data available are limited and originate from post-marketing surveillance 1.
• For nausea associated with migraine in pregnancy, metoclopramide can be used 1.

Preventive Migraine Medications

Preventive migraine medications are best avoided during pregnancy owing to the potential for fetal harm. However, if preventive therapy is considered clinically indicated because of frequent and disabling migraine attacks, propranolol or amitriptyline can be used under specialist supervision to adequately monitor any potential fetal harm 1.

• Topiramate, candesartan, and sodium valproate are contraindicated due to their potential to cause adverse effects on the fetus 1.

From the FDA Drug Label

If pregnant or breast-feeding ask a health professional before use. The safest pharmacological treatment for migraine headaches during pregnancy is acetaminophen (PO), but only under the guidance of a health professional 2.

• It is recommended to consult a health professional before using acetaminophen (PO) during pregnancy.

From the Research

Safest Pharmacological Treatments for Migraine Headaches during Pregnancy

• The safest treatment options for migraine headaches during pregnancy include:
  • Paracetamol (acetaminophen) as the first choice for acute treatment 3, 4, 5, 6, 7
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, but with caution and avoidance during the last trimester 3, 4, 5
  • Prochlorperazine for treatment of nausea, which is unlikely to be harmful during pregnancy 3
  • Metoclopramide, which is probably acceptable to use during the second and third trimester 3
  • Beta-blockers such as metoprolol and propranolol for prophylactic treatment, but only in severe cases 3, 7

Contraindicated Medications

• The following medications are contraindicated in women who are pregnant:
  • Triptans (sumatriptan, zolmitriptan, naratriptan) 3
  • Dihydroergotamine and ergotamine tartrate 3

Non-Pharmacological Approaches

• Non-pharmacological approaches, such as relaxation, sleep, massage, ice packs, and biofeedback, should be tried first to treat migraine in women who are pregnant 3, 4, 5, 6
• Lifestyle modifications and avoiding known triggers are also recommended 5, 6