What is the recommended treatment for headaches during pregnancy?

Treatment of Headaches During Pregnancy

Paracetamol (acetaminophen) is the first-line treatment for headaches during pregnancy, with a recommended dose of 1000 mg per dose, as it is considered safe throughout all trimesters. 1

First-Line Treatment Options

Non-Pharmacological Approaches

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

Pharmacological Treatment

1. Paracetamol (Acetaminophen)

   • Dosage: 1000 mg per dose
   • Administration: Oral or suppository (preferred if nausea present)
   • Safety: Safe throughout all trimesters 1, 2
   • Note: While FDA labeling recommends consulting a healthcare professional before use during pregnancy 3, clinical guidelines consistently identify it as the safest option

2. Metoclopramide

   • Can be used for nausea associated with migraine 1
   • Most appropriate during second and third trimesters 2
   • May be combined with diphenhydramine for better efficacy than codeine 4

Second-Line Treatment Options (When First-Line Fails)

1. NSAIDs (Ibuprofen, Naproxen)

   • Use only during second trimester 1
   • Avoid in first trimester (risk of miscarriage)
   • Avoid in third trimester (risk of premature closure of ductus arteriosus)
   • Short-term, episodic use only 2

2. Sumatriptan

   • Consider only when other treatments fail 1, 5
   • Requires specialist supervision
   • Evidence suggests it may not be associated with adverse fetal effects 4
   • Contraindicated in women with history of cardiovascular disease

Treatments to Avoid During Pregnancy

• Opioids - Risk of dependence and rebound headaches 1
• Butalbital - Potential risks to fetus 1
• Ergotamine derivatives - Contraindicated due to oxytocic properties 2
• Topiramate - Associated with higher rate of fetal abnormalities 6

Preventive Treatment

Preventive treatment should only be considered in severe cases with at least three prolonged and debilitating attacks per month that don't respond to symptomatic therapy 1.

1. Propranolol

   • First choice for preventive treatment
   • Dosage: 80-160 mg once or twice daily in extended-release formulations
   • Best safety profile during pregnancy 1, 2, 7

2. Amitriptyline

   • Second choice if propranolol is contraindicated
   • Dosage: 10-100 mg at night
   • Requires specialist supervision 1

Special Considerations

Severe or Atypical Headaches

• New-onset headaches during pregnancy, especially with hypertension, should be evaluated for preeclampsia 6
• Consider idiopathic intracranial hypertension in pregnant women with persistent headaches and visual symptoms 6

Postpartum and Breastfeeding

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

Treatment Algorithm

1. Start with non-pharmacological approaches for all headaches
2. For mild to moderate pain: Paracetamol 1000 mg
3. If inadequate relief or nausea present:
   • Add metoclopramide for nausea
   • Consider paracetamol as suppository
4. For moderate to severe pain unresponsive to paracetamol:
   • Second trimester only: Consider NSAIDs for short-term use
   • Any trimester if severe and unresponsive: Consider sumatriptan under specialist supervision
5. For frequent, severe headaches requiring prevention:
   • First choice: Propranolol
   • Second choice: Amitriptyline (if propranolol contraindicated)

Remember that most migraines improve during pregnancy, particularly in the second and third trimesters 2, 7, but appropriate treatment is important as suboptimally treated headaches could have negative consequences for both mother and fetus 5.