From the Guidelines
Migraine prophylaxis and treatment during pregnancy should prioritize fetal safety while managing maternal symptoms, with paracetamol as the first-line medication for acute treatment and propranolol or amitriptyline for preventive therapy under specialist supervision. When considering migraine management during pregnancy, it is crucial to weigh the benefits of treatment against the potential risks to the fetus. According to the most recent guidelines 1, non-pharmacological approaches such as regular sleep patterns, stress management, and avoiding known triggers should be the initial focus. For acute migraine attacks, the following medications can be considered:
- Paracetamol as the first-line medication, due to its relatively poor efficacy but safer profile compared to other options 1
- NSAIDs can be used only during the second trimester, with caution and under specialist supervision 1
- Triptans, such as sumatriptan, should be used only under strict supervision due to limited safety data 1
- Metoclopramide can be used for nausea associated with migraine in pregnancy 1 In terms of preventive therapy,
- Propranolol or amitriptyline are the preferred options when preventive therapy is clinically indicated, due to their relatively safer profiles compared to other medications 1
- Topiramate, candesartan, and sodium valproate are contraindicated due to their potential for fetal harm, with sodium valproate being known to be teratogenic 1 It is essential to individualize treatment decisions based on migraine severity, pregnancy stage, and the patient's response to previous treatments, always prioritizing fetal safety and maternal well-being.
From the Research
Migraine Prophylaxis and Treatment During Pregnancy
- Migraine affects about 25% of women during childbearing years, and treatment is often necessary because maternal and fetal risks related to acute attacks may be more harmful than the therapy itself 2.
- The following drugs should be preferred for the treatment of acute migraine attacks in pregnant women: paracetamol, NSAIDs, and sumatriptan 2, 3.
- Migraine prophylaxis should be undertaken when patients experience at least three prolonged severe attacks a month that are particularly incapacitating or unresponsive to symptomatic therapy and likely to result in complications 2.
- Non-pharmacologic approaches should be preferred, but if they are not effective, preventive treatment should include low doses of β-blockers and amitriptyline 2, 4.
- Non-pharmacological management of migraine during pregnancy includes hygiene and behavior measures, such as regular meals and balanced diet, restriction of alcohol and smoking, regular sleeping pattern, moderate physical exercise, and relaxation 5.
- Relaxation techniques, in particular biofeedback, and acupuncture have accumulated sufficient evidence in support of their efficacy and safety for non-pharmacological migraine prophylaxis 5.
- Some vitamins and dietary supplements, such as magnesium, riboflavin, and coenzyme Q10, have been proposed for migraine prophylaxis, although their prophylactic properties are low, their lack of severe adverse effects makes them good treatment options 5, 6.
Pharmacological Treatment
- Paracetamol is the preferred drug for acute treatment throughout pregnancy 3.
- If paracetamol is not sufficiently effective, sporadic use of sumatriptan can be considered 3.
- NSAIDs, such as ibuprofen, can also be used under certain circumstances, though their intake in the first and third trimesters is associated with specific risks and contraindications 3.
- Preventive treatment should only be considered in the most severe cases, and should include low doses of β-blockers and amitriptyline 2, 4.
Safety of Antimigraine Medications
- The safety of antimigraine medications during pregnancy and breastfeeding has been summarized in recent reviews, and provides treatment recommendations for use in clinical practice 3.
- High-dose valproate is the only antiepileptic drug available for migraine prophylaxis that has been shown to cause long-term cognitive effects in infants exposed during gestation 4.
- Beta-blockers and calcium-channel blockers have a low likelihood of compromising fetal well-being and can be used for migraine prevention during pregnancy 4.