From the Guidelines
The recommended workup and treatment for a 32-week pregnant female with migraines should prioritize non-pharmacological approaches and safe pharmacological options, with paracetamol as the first-line medication for acute treatment, as stated in the 2021 study published in Nature Reviews Neurology 1.
Key Considerations
- A thorough history and physical examination are crucial to distinguish between primary migraines and secondary headaches that may indicate serious conditions like preeclampsia.
- Non-pharmacological approaches, including adequate hydration, regular sleep patterns, stress reduction techniques, and trigger avoidance, should be tried first.
- Safe first-line pharmacological options include paracetamol, which should be used as the first-line medication for acute treatment of migraine in pregnancy, despite relatively poor efficacy, as noted in the study 1.
Pharmacological Treatment
- Paracetamol should be used as the first-line medication for acute treatment, with NSAIDs limited to the second trimester due to potential risks, as indicated in the study 1.
- Metoclopramide can be used for nausea associated with migraine in pregnancy, as mentioned in the study 1.
- Triptans, such as sumatriptan, should be used only under strict supervision of a specialist due to limited safety data, as stated in the study 1.
Preventive Therapy
- Preventive migraine medications are best avoided during pregnancy due to potential fetal harm, but if necessary, propranolol or amitriptyline may be considered under specialist supervision, as noted in the study 1.
- Topiramate, candesartan, and sodium valproate are contraindicated due to adverse effects on the fetus or teratogenic properties, as indicated in the study 1.
Monitoring and Consultation
- Regular fetal monitoring is essential, especially when using medications, to ensure maternal and fetal safety.
- Consultation with both neurology and maternal-fetal medicine specialists is recommended to develop a personalized treatment plan, as the study suggests careful consideration of treatment options during pregnancy 1.
From the Research
Workup for Migraine in Pregnancy
- A thorough medical history and physical examination are essential to diagnose and manage migraines in pregnant women 2, 3.
- Identifying and avoiding potential triggers is crucial in managing migraines during pregnancy 3, 4.
Treatment of Migraine in Pregnancy
- Non-pharmacological approaches, such as lifestyle modifications, relaxation techniques, and acupuncture, are preferred as first-line treatment 5, 4.
- Acetaminophen is the preferred drug for acute treatment throughout pregnancy 2, 6, 4.
- If acetaminophen is not effective, sporadic use of sumatriptan or NSAIDs like ibuprofen can be considered, taking into account trimester-specific risks 2, 6, 4.
- Preventive treatment, including low doses of β-blockers or amitriptyline, may be considered in severe cases, but should be used cautiously 6, 3, 4.
Special Considerations
- Migraine with aura may be overrepresented in women whose migraines worsen during pregnancy 3.
- Women with menstrual migraines or migraines without aura are more likely to experience improvement or remission of symptoms during pregnancy 3, 4.
- Postpartum, many women experience a recurrence of migraines, likely due to hormonal changes 4.