From the Guidelines
Migraine prophylaxis and treatment during pregnancy should prioritize the use of paracetamol as the first-line medication for acute treatment, and propranolol or amitriptyline for preventive therapy under specialist supervision. When considering treatment options, it is essential to weigh the potential benefits against the risks to the fetus. According to a recent study published in Nature Reviews Neurology 1, paracetamol is recommended as the first-line medication for acute treatment of migraine in pregnancy due to its relatively poor efficacy but safer profile compared to other options.
For nausea associated with migraine in pregnancy, metoclopramide can be used 1. However, preventive migraine medications are best avoided during pregnancy owing to the potential for fetal harm. If preventive therapy is considered clinically indicated, propranolol or amitriptyline are preferred options, with the former being the first choice due to its better safety profile 1. Topiramate, candesartan, and sodium valproate are contraindicated due to their potential to cause adverse effects on the fetus, with sodium valproate being known to be teratogenic 1.
Some key points to consider when managing migraines during pregnancy include:
- Using paracetamol as the first-line medication for acute treatment
- Considering metoclopramide for nausea associated with migraine
- Avoiding preventive migraine medications unless clinically indicated
- Using propranolol or amitriptyline for preventive therapy under specialist supervision
- Avoiding topiramate, candesartan, and sodium valproate due to their potential to cause fetal harm.
It is crucial to develop a treatment plan in consultation with both a neurologist and obstetrician to balance migraine management with fetal safety, as emphasized in the study 1.
From the Research
Migraine Prophylaxis and Treatment During Pregnancy
- Migraine affects about 25% of women during childbearing years, and few data are available about the risks connected with most antimigraine drugs during pregnancy 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.
- Paracetamol is the preferred drug for acute treatment throughout pregnancy, and 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, 4.
Treatment Options During Pregnancy
- Nondrug therapies (relaxation, sleep, massage, ice packs, biofeedback) should be tried first to treat migraine in women who are pregnant 4.
- For treatment of acute migraine attacks, 1000 mg of paracetamol (acetaminophen) preferably as a suppository is considered the first choice drug treatment 4.
- The risks associated with use of aspirin (acetylsalicylic acid) and ibuprofen are considered to be small when the agents are taken episodically and if they are avoided during the last trimester of pregnancy 4.
- Prophylactic treatment is rarely indicated, and the only agents that can be given during pregnancy are the beta-blockers metoprolol and propranolol 4, 5.
Preventive Treatment
- Preventive treatment should only be considered in the most severe cases, and patients should be advised to try to maintain a regular lifestyle, with regular sleep, meals, exercise, and management of stress 5.
- Patients can choose between evidence-based nutraceuticals such as riboflavin, feverfew, butterbur, or coenzyme Q10, or more traditional pharmacotherapeutics 5.
- Beta-adrenoceptor blockers are particularly useful in patients also suffering from hypertension or tachycardia, and topiramate has become a first choice for episodic as well as chronic migraine 5.
- Magnesium may be particularly useful during pregnancy, and acupuncture may be another alternative, although controlled trials have failed to differentiate its effect from placebo 5, 6.