What is the recommended treatment for a headache during pregnancy?

Management of Headache During Pregnancy

Acetaminophen (paracetamol) is the first-line medication for headache management during pregnancy, with non-pharmacological approaches being essential complementary strategies. 1

First-Line Treatment Options

Non-Pharmacological Approaches (Try First)

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

First-Line Medication

• Acetaminophen (paracetamol): 1000 mg, safe in all trimesters 1
  • Preferably as a suppository for better absorption during acute attacks 2

Second-Line Treatment Options

If acetaminophen is ineffective, consider:

NSAIDs (Second Trimester Only)

• Ibuprofen: 400-800 mg every 6 hours
• Naproxen: 275-550 mg every 2-6 hours
• Important: Avoid NSAIDs in the third trimester due to risk of premature closure of the ductus arteriosus 1

For Nausea Management

• Metoclopramide: Safe in all trimesters, especially useful when nausea is prominent 1
• Prochlorperazine: Unlikely to be harmful during pregnancy 2

Severe or Refractory Headaches

For severe migraine attacks that don't respond to first-line treatments:

• Sumatriptan: Use with caution and only when other treatments fail 1
  • Current evidence suggests it may not be associated with adverse fetal effects, but should still be used cautiously 1

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

   • First choice for prevention during pregnancy 1
   • Best safety profile among preventive medications 1

2. Metoprolol: Alternative beta-blocker option 2

3. Amitriptyline: 10-100 mg at night

   • Second choice if propranolol is contraindicated
   • Requires specialist supervision 1

Important Considerations and Red Flags

Medication to Avoid During Pregnancy

• Topiramate: Associated with higher rates of fetal abnormalities 3, 1
• Ergot alkaloids (including dihydroergotamine and ergotamine tartrate): Contraindicated due to teratogenicity 2
• Valproate: Should be avoided due to teratogenic effects

Warning Signs Requiring Urgent Evaluation

• New-onset headaches during pregnancy, especially with hypertension (evaluate for preeclampsia) 1
• Persistent headaches with visual symptoms (consider idiopathic intracranial hypertension) 3, 1
• "Red flag" symptoms suggesting secondary headache: sudden onset, fever, focal neurological deficits, altered mental status 4

Secondary Headaches to Consider

Pregnant women with severe or unusual headaches should be evaluated for:

• Stroke
• Cerebral venous thrombosis
• Preeclampsia/eclampsia
• Idiopathic intracranial hypertension
• Reversible cerebral vasoconstriction syndrome 4

Postpartum and Breastfeeding Considerations

• Ibuprofen and sumatriptan: Safe during breastfeeding 1
• Propranolol: First choice if preventive medication is required during breastfeeding 1
• Acetaminophen: Remains the preferred acute medication during postpartum and breastfeeding periods 1

Medication Overuse Warning

Be vigilant about medication overuse headache risk with frequent use of acute medications, as warned by the American College of Physicians 1. This condition is defined as headache occurring on 15 or more days per month for at least 3 months due to overuse of acute medication 3.

Remember that treating headache during pregnancy is important to limit excessive use of over-the-counter pain remedies, dehydration, and pain-related disability 5. Early and appropriate management benefits both mother and baby.