What are the recommended treatments for managing migraine in pregnancy?

Managing Migraine in Pregnancy

Acetaminophen (paracetamol) is the first-line medication for acute migraine treatment during pregnancy, while non-pharmacological approaches should always be tried initially. 1

Non-Pharmacological Management (First-Line)

Before considering medications, these approaches should be implemented:

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

Acute Treatment Algorithm

1. First-line: Acetaminophen 1000 mg (safe in all trimesters) 1, 2

   • Preferably as a suppository for better absorption 3

2. Second-line (if acetaminophen is ineffective):

   • Sumatriptan - can be considered for sporadic use when other treatments fail 1, 2
   • Metoclopramide - safe in all trimesters for associated nausea 1

3. Third-line (with caution):

   • NSAIDs (ibuprofen 400-800 mg every 6 hours, naproxen 275-550 mg every 2-6 hours)
     • Only in second trimester
     • Avoid in first and third trimesters due to specific risks 1, 2

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.

Preventive medication algorithm:

1. First choice: Propranolol 80-160 mg once or twice daily (extended-release)

   • Has the best safety profile during pregnancy 1

2. Second choice (only if propranolol is contraindicated):

   • Amitriptyline 10-100 mg at night
   • Requires specialist supervision 1

Important Considerations and Warnings

• New-onset headaches during pregnancy, especially with hypertension, should be evaluated for preeclampsia 1

• Medication overuse headache risk should be monitored with frequent use of acute medications 1

• Medications to avoid:

  • Topiramate - associated with higher rates of fetal abnormalities 1
  • Ergotamine preparations - contraindicated 3

• Magnesium sulfate considerations:

  • While sometimes used for migraine, it requires careful monitoring if used during pregnancy
  • Can cause fetal abnormalities with prolonged use (>5-7 days)
  • Potential for neuromuscular or respiratory depression in newborns 4

Natural Course of Migraine During Pregnancy

Most women (55-90%) experience improvement in migraine symptoms during pregnancy, particularly during the second and third trimesters 3, 5. This is likely due to stable estrogen levels during pregnancy 6. However, symptoms often recur shortly after delivery when hormone levels change rapidly 2.

Women with menstrual migraine or migraine without aura tend to experience the greatest improvement during pregnancy 5. A small percentage (4-8%) may experience worsening of migraines, particularly those with migraine with aura 7.

Preconception Counseling

Patients should always be counseled about medication risks before conception when possible 1. Women with migraine with aura should avoid combined hormonal contraceptives due to significantly increased risk of stroke 1.