What are safe headache medications during pregnancy?

Safe Headache Medications During Pregnancy

Acetaminophen (paracetamol) is the first-line medication for headache management during pregnancy, with the best safety profile across all trimesters. 1, 2

First-Line Treatment Options

Acute Headache Treatment

• Acetaminophen (Paracetamol): 1000 mg as needed
  • Safe during all trimesters 1
  • FDA-approved for use during pregnancy with healthcare provider consultation 2
  • Most widely used medication during pregnancy (used by 40-65% of pregnant women) 3

Non-Pharmacological Approaches (should be tried first)

• Relaxation techniques
• Adequate sleep hygiene
• Massage
• Ice packs
• Biofeedback
• Avoiding known headache triggers
• Maintaining regular meals and hydration 1

Second-Line Treatment Options

NSAIDs (Use with Caution)

• Ibuprofen: 400-800 mg every 6 hours

  • Safe only during second trimester 1
  • Avoid during first and third trimesters due to specific risks 1, 4

• Naproxen: 275-550 mg every 2-6 hours

  • Safe only during second trimester 1
  • Avoid during first and third trimesters 1

For Severe Migraine Attacks

• Sumatriptan: Can be considered when other treatments fail 1, 4

  • Use only after non-response to acetaminophen 5
  • Contraindicated according to older guidelines but newer evidence suggests sporadic use may be acceptable 4

• Metoclopramide: For associated nausea

  • Safe during all trimesters 1
  • Most appropriate during second and third trimesters 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.

First-Choice Preventive

• Propranolol: 80-160 mg once or twice daily
  • Best safety profile during pregnancy 1, 6
  • Can be used across all trimesters 1

Second-Choice Preventive

• Amitriptyline: 10-100 mg at night
  • Use with caution and only if propranolol is contraindicated 1
  • Requires specialist supervision 1

Important Considerations

Medication to Avoid During Pregnancy

• Ergotamine and dihydroergotamine: Contraindicated due to teratogenicity 6, 7
• Topiramate: Associated with higher rates of fetal abnormalities 1

Special Warnings

1. New-onset headaches during pregnancy, especially with hypertension, should be evaluated for preeclampsia 1
2. Idiopathic intracranial hypertension should be considered in pregnant women with persistent headaches and visual symptoms 1
3. Avoid medication overuse headache by limiting frequency of acute medications 1

Migraine Pattern During Pregnancy

• 55-90% of women with migraine experience improvement during pregnancy, particularly in the second and third trimesters 6, 5
• Women with menstrual migraine are more likely to experience improvement 6, 7
• A small percentage (4-8%) may experience worsening, particularly those with migraine with aura 7

By following this stepwise approach to headache management during pregnancy, clinicians can provide effective symptom relief while minimizing risks to both mother and fetus.