From the Guidelines
Treating migraines during pregnancy should prioritize the use of paracetamol as the first-line medication for acute treatment, due to its relatively safe profile compared to other options. When considering treatment for migraine headaches in pregnancy, it's crucial to weigh the potential benefits against the risks to both the mother and the fetus. According to the most recent guidelines 1, paracetamol is recommended as the initial treatment for acute migraine attacks, despite its relatively poor efficacy, because it poses the least risk to the fetus.
For nausea associated with migraine, metoclopramide can be used, as suggested by 1. However, the use of NSAIDs is restricted to the second trimester, and triptans, such as sumatriptan, should only be considered under strict specialist supervision due to limited safety data.
In terms of preventive therapy, propranolol or amitriptyline are the preferred options if clinically indicated, but their use must be closely monitored by a specialist. It's essential to avoid certain medications like topiramate, candesartan, and sodium valproate due to their potential for fetal harm, as highlighted in 1.
Key considerations for treating migraines in pregnancy include:
- Using paracetamol as the first-line treatment for acute attacks
- Restricting NSAID use to the second trimester
- Limiting triptan use to severe cases under specialist supervision
- Avoiding certain preventive medications due to fetal risk
- Monitoring any medication use closely under specialist care, as advised by 1.
From the Research
Migraine Headache Treatment in Pregnancy
- The occurrence of migraine in women is influenced by hormonal changes throughout the lifecycle, with a beneficial effect of pregnancy on migraine observed in 55 to 90% of women who are pregnant 2.
- Nondrug therapies such as relaxation, sleep, massage, ice packs, and biofeedback should be tried first to treat migraine in women who are pregnant 2.
- For treatment of acute migraine attacks, 1000 mg of paracetamol (acetaminophen) is considered the first choice drug treatment, while the risks associated with use of aspirin and ibuprofen are considered to be small when taken episodically and avoided during the last trimester of pregnancy 2.
- The 'triptans' (sumatriptan, zolmitriptan, naratriptan), dihydroergotamine, and ergotamine tartrate are contraindicated in women who are pregnant, while prochlorperazine for treatment of nausea is unlikely to be harmful during pregnancy 2.
Pharmacological Treatment Options
- Metoclopramide is probably acceptable to use during the second and third trimester, and combination metoclopramide and diphenhydramine may be more effective than codeine for migraine or tension headache 3.
- Triptans may not be associated with fetal/child adverse effects, and low-dose aspirin may not be associated with fetal/child adverse effects either 3.
- Beta-blockers such as metoprolol and propranolol can be used for migraine prevention during pregnancy, and calcium-channel blockers may also be a safe option 2, 4.
Non-Pharmacological Treatment Options
- Non-pharmacological strategies should be the first-line treatment of migraines, including relaxation, sleep, massage, ice packs, and biofeedback 2, 4.
- A well-considered choice should be made concerning the use of medication, taking into account all the benefits and possible risks, and treatment should not be postponed as an undermanaged headache can lead to stress, sleep deprivation, depression, and poor nutritional intake 5.
- Women with a history of migraine should be offered preconception counselling to address pregnancy-related concerns and advice on the use of medicines, which should be supported by high-quality information 6.