What are the recommended treatments for headaches in pregnancy?

Headache Treatment in Pregnancy

Acetaminophen (paracetamol) is the first-line medication for treating headaches during pregnancy, with non-pharmacological approaches always recommended as initial and complementary treatment. 1

First-Line Approaches

Non-Pharmacological Treatments

• Relaxation techniques
• Adequate sleep hygiene
• Massage
• Ice packs
• Biofeedback
• Avoiding known migraine triggers
• Maintaining regular meals and hydration 1, 2

First-Line Medication

• Acetaminophen (paracetamol): 1000 mg as needed 1, 3
  • Safe during all trimesters
  • Used by 40-65% of pregnant women
  • FDA approved with recommendation to consult healthcare provider 3

Second-Line Treatments for Acute Headaches

When acetaminophen is insufficient:

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

  • Use with caution in all trimesters
  • Recent evidence suggests it may not be associated with adverse fetal effects 1

• NSAIDs (only in second trimester):

  • Ibuprofen: 400-800 mg every 6 hours 1
  • Naproxen: 275-550 mg every 2-6 hours 1
  • Caution: Avoid in first and third trimesters due to specific risks 1, 4

• Anti-emetics for nausea component:

  • Metoclopramide: Safe in all trimesters 1
  • Consider especially when nausea is a prominent symptom 5

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. First choice: Propranolol (80-160 mg once or twice daily in extended-release formulations) 1, 6

   • Best safety profile during pregnancy

2. Second choice: Amitriptyline (10-100 mg at night) 1

   • Only if propranolol is contraindicated
   • Requires specialist supervision

Important Considerations and Red Flags

• New-onset headaches during pregnancy, especially with hypertension, should be evaluated for preeclampsia 1
• Idiopathic intracranial hypertension should be considered in pregnant women with persistent headaches and visual symptoms 1
• Avoid medication overuse headache risk with frequent use of acute medications 1
• Medications to avoid:
  • Topiramate (associated with higher rate of fetal abnormalities) 1
  • Ergotamine derivatives 7

Treatment Algorithm

1. Start with non-pharmacological approaches for all headaches
2. For mild to moderate pain: Acetaminophen 1000 mg
3. If inadequate relief:
   • Second trimester only: Consider NSAIDs
   • Any trimester with severe symptoms: Consider sumatriptan (sporadic use)
4. For nausea: Add metoclopramide
5. For frequent severe headaches (≥3 debilitating attacks/month):
   • Consider propranolol for prevention
   • Amitriptyline if propranolol contraindicated

Special Considerations

• Most women (60-70%) experience improvement in migraine during pregnancy, particularly in the second and third trimesters 6
• Women with migraine onset at menarche and those with perimenstrual migraine are more likely to experience improvement 6
• A small percentage (4-8%) may experience worsening migraines during pregnancy 6
• Chiropractic care involving spinal manipulative therapy may be beneficial for some patients 2

Untreated severe headaches during pregnancy can potentially lead to complications including premature labor, hypertension, and low birth weight babies, making appropriate management essential 8.