What is the recommended treatment for headaches in pregnant women?

From the Guidelines

The first-line treatment for headaches in pregnant women should be paracetamol, due to its relatively safe profile for the fetus, as recommended by the most recent guidelines 1. When managing headaches in pregnant women, it's crucial to consider the potential harm to the fetus and balance this with the need for effective symptom relief.

• Non-medication approaches such as rest, hydration, and stress reduction should be encouraged as initial steps.
• If medication is necessary, paracetamol is the preferred choice, typically at a dose of 500-1000 mg every 6 hours, not exceeding 4000 mg daily, as it has a better safety profile compared to other options 1.
• For nausea associated with migraine, metoclopramide can be used, offering relief without significant risk to the fetus 1.
• NSAIDs, like ibuprofen, should be used with caution and only during the second trimester, while triptans, such as sumatriptan, are reserved for use under strict specialist supervision due to limited safety data 1.
• Preventive migraine medications are generally avoided during pregnancy, but if necessary, propranolol or amitriptyline may be considered under specialist care, given their relatively safer profiles compared to other preventive medications 1.
• It's essential for pregnant women to be aware of the risks associated with certain medications and to seek medical attention immediately if they experience severe, persistent headaches or other concerning symptoms, as these could indicate complications like preeclampsia.

From the FDA Drug Label

1. Use in Specific Populations 8. 1 Pregnancy Risk Summary Data from a prospective pregnancy exposure registry and epidemiological studies of pregnant women have not detected an increased frequency of birth defects or a consistent pattern of birth defects among women exposed to sumatriptan compared with the general population The Sumatriptan/Naratriptan/Treximet (sumatriptan and naproxen sodium) Pregnancy Registry, a population-based international prospective study, collected data for sumatriptan from January 1996 to September 2012 The occurrence of major birth defects (excluding fetal deaths and induced abortions without reported defects and all spontaneous pregnancy losses) during first-trimester exposure to sumatriptan was 4.2% (20/478 [95% CI: 2.6% to 6.5%]) and during any trimester of exposure was 4.2% (24/576 [95% CI: 2.7% to 6.2%])

The recommended treatment for headaches in pregnant women is not explicitly stated in the provided drug label. However, sumatriptan may be considered for the treatment of migraines during pregnancy, as the data from the pregnancy registry and epidemiological studies do not suggest an increased risk of birth defects.

• The occurrence of major birth defects during first-trimester exposure to sumatriptan was 4.2% 2. It is essential to weigh the benefits and risks of using sumatriptan during pregnancy and consider alternative treatment options. Key considerations for the use of sumatriptan in pregnant women include:
• The potential risks of embryolethality, fetal abnormalities, and pup mortality associated with sumatriptan use in animal studies 2.
• The limited data available on the use of sumatriptan during pregnancy, particularly in the first trimester 2.

From the Research

Treatment Options for Headaches in Pregnant Women

• Nondrug therapies such as relaxation, sleep, massage, ice packs, and biofeedback should be tried first to treat migraine in women who are pregnant 3
• For treatment of acute migraine attacks, 1000 mg of paracetamol (acetaminophen) is considered the first choice drug treatment, preferably as a suppository 3
• Aspirin and ibuprofen can be used episodically, but should be avoided during the last trimester of pregnancy due to associated risks 3
• Triptans, dihydroergotamine, and ergotamine tartrate are contraindicated in women who are pregnant 3

Pharmacologic Treatment

• Acetaminophen and codeine can be used safely as abortive agents for migraine 4
• ASA and NSAIDs (ibuprofen, naproxen) can be used as a second choice, but not for long periods of time, and should be avoided during the last trimester 4
• Metoclopramide can be used for treatment of nausea, but should be restricted to the third trimester 4
• Beta-adrenergic receptor antagonists (e.g., propranolol) can be used for prophylactic treatment 4

Non-Pharmacologic Treatment

• Avoiding potential triggers is recommended as a first step in managing migraine during pregnancy 4
• Nonpharmacologic therapies such as relaxation, sleep, massage, ice packs, and biofeedback can be used to treat migraine in women who are pregnant 3
• However, there is insufficient evidence regarding the effectiveness of non-pharmacologic treatments for primary headaches in pregnant women 5

Safety of Medications

• Most drugs are not teratogenic, but adverse effects can depend on the dosage and route of administration, and the timing of exposure relative to fetal development 6
• Triptans may not be associated with fetal/child adverse effects, according to low-soe evidence 5
• Low-dose aspirin may not be associated with fetal/child adverse effects, according to indirect evidence with low-to-moderate strength of evidence 5