From the Guidelines
The recommended treatment for headaches in pregnancy begins with non-medication approaches such as rest, hydration, regular meals, stress reduction, and cold or warm compresses. When medication is necessary, acetaminophen (Tylenol) is considered the safest first-line option, typically at 500-1000 mg every 4-6 hours, not exceeding 4000 mg daily 1. For more severe headaches, especially migraines, metoclopramide (Reglan) 10 mg orally or intravenously can help with both pain and nausea 1. Caffeine in limited amounts (under 200 mg daily) may also provide relief. NSAIDs like ibuprofen should be avoided, particularly after 20 weeks gestation due to risks of premature closure of the fetal ductus arteriosus and potential kidney problems 1. Triptans may be considered for severe migraines when benefits outweigh risks, but only after consultation with an obstetrician 1. Preventive measures are important for women with recurrent headaches, including maintaining regular sleep patterns, eating frequent small meals, and avoiding known triggers. These recommendations balance symptom relief with fetal safety, as many medications cross the placenta and could potentially affect fetal development. It's worth noting that while other studies discuss various treatment options for migraines, such as CGRP antagonists-gepants or ergot alkaloid (dihydroergotamine) 1, the primary concern in pregnancy is minimizing risk to the fetus, making acetaminophen and metoclopramide preferred choices due to their safety profiles 1.
From the Research
Treatment Options for Headaches in Pregnancy
- Nondrug therapies such as relaxation, sleep, massage, ice packs, and biofeedback should be tried first to treat headaches in pregnant women 2
- For acute migraine attacks, 1000 mg of paracetamol (acetaminophen) is considered the first choice drug treatment, preferably as a suppository 2
- Aspirin and ibuprofen may be used episodically, but should be avoided during the last trimester of pregnancy due to potential risks 2
- Triptans, dihydroergotamine, and ergotamine tartrate are contraindicated in pregnant women 2
Pharmacologic Treatment
- Metoclopramide and diphenhydramine may be effective for treating headaches in pregnancy when acetaminophen alone is ineffective 3
- Combination metoclopramide and diphenhydramine may be more effective than codeine for migraine or tension headache 4
- Acetaminophen is the mainstay for treating uncomplicated migraine in pregnancy, especially during the first trimester 5
- Partial agonist opioids may be used if typical migraine attacks persist in the second and third trimesters 5
Non-Pharmacologic Treatment
- Non-pharmacologic treatments such as lifestyle modifications and alternative therapies may be recommended, but there is insufficient evidence to support their effectiveness 4
- Heightened pharmacovigilance is necessary to better inform the treatment of headaches in pregnant women 5
Preventive Treatment
- Preventive treatment is rarely indicated and should be used only when necessary 2
- Beta-blockers such as metoprolol and propranolol may be used for preventive treatment, but only during the second and third trimesters 2
- Calcium channel blockers and antihistamines may not be associated with fetal/child adverse effects and may be considered for preventive treatment 4