What are safe medications for migraines during pregnancy?

Safe Medications for Migraines During Pregnancy

Paracetamol (acetaminophen) is the first-line medication for acute treatment of migraine during pregnancy, despite its relatively low efficacy, at a dose of 1000 mg per dose, preferably as a suppository to avoid absorption issues in case of nausea. 1

Acute Treatment Options

First-Line Treatment

• Paracetamol (acetaminophen)
  • Dosage: 1000 mg per dose
  • Safety: Considered safest option throughout all trimesters 2, 1
  • Administration: Preferably as suppository if nausea is present

Second-Line Treatment (with restrictions)

• NSAIDs (only during second trimester)
  • Ibuprofen: 400-800 mg every 6 hours (max 2.4 g/day) 1
  • Naproxen: 275-550 mg every 2-6 hours (max 1.5 g/day) 1
  • Caution: Must be avoided in first and third trimesters due to risks of miscarriage and premature closure of ductus arteriosus 2

For Severe Cases (specialist supervision only)

• Sumatriptan
  • Use only when other treatments fail 2, 1
  • Requires strict specialist supervision
  • Most safety data comes from post-marketing surveillance 2

For Associated Nausea

• Metoclopramide - can be used for nausea associated with migraine 2, 1
• Prochlorperazine - unlikely to be harmful during pregnancy 3

Preventive Treatment

Preventive medications should generally be avoided during pregnancy due to potential fetal harm. However, if a patient experiences at least three prolonged and severe attacks per month that are particularly debilitating or unresponsive to acute therapy, preventive treatment may be considered 1.

When Prevention Is Necessary

1. First choice: Propranolol

   • Dosage: 80-160 mg once or twice daily in extended-release formulations 2, 1
   • Has the best safety profile during pregnancy 2

2. Second choice: Amitriptyline

   • Dosage: 10-100 mg at night 1
   • Only if propranolol is contraindicated 2, 1
   • Requires specialist supervision 2

Contraindicated Medications

• Topiramate - associated with adverse fetal effects 2, 1
• Candesartan - associated with adverse fetal effects 2, 1
• Sodium valproate - known teratogen, absolutely contraindicated 2, 1
• Opioids - risk of dependence and rebound headaches 1
• Butalbital - should not be used 2

Postpartum and Breastfeeding Considerations

During the postpartum period and while breastfeeding:

• Paracetamol remains the preferred acute medication 2
• Ibuprofen and sumatriptan are considered safe during breastfeeding 2, 1
• Propranolol is the first choice if preventive medication is required 2, 1

Non-Pharmacological Approaches

Non-pharmacological approaches should always be first-line and used to complement any required drug treatment:

• Relaxation techniques
• Adequate sleep hygiene
• Massage
• Ice packs
• Biofeedback
• Avoiding known migraine triggers
• Maintaining regular meals and hydration

Clinical Pitfalls and Caveats

1. Migraine often improves during pregnancy (55-90% of women), especially in the second and third trimesters 3, 4
2. Women with menstrual migraine are more likely to experience improvement 3
3. A small percentage may experience worsening, particularly those with migraine with aura 5
4. Always counsel patients about medication risks before conception when possible
5. Avoid combined hormonal contraceptives in women with migraine with aura due to increased stroke risk 1
6. Be aware of medication overuse headache risk with frequent use of acute medications 2

Remember that the goal is to provide optimal treatment while minimizing possible risks to both mother and fetus. Always use the lowest effective dose for the shortest duration necessary.