What are safe treatment options for migraines during pregnancy?

Safe Treatments for Migraines During Pregnancy

Acetaminophen (paracetamol) is the first-line medication for managing migraines during pregnancy, with non-pharmacological approaches as foundational treatment. 1

First-Line Treatments

Non-Pharmacological Approaches

• Always begin with and maintain these approaches throughout pregnancy:
  • Relaxation techniques
  • Adequate sleep hygiene
  • Massage
  • Ice packs
  • Biofeedback
  • Avoiding known migraine triggers
  • Maintaining regular meals and hydration 1

First-Line Medication

• Acetaminophen (paracetamol)
  • Dosage: 1000 mg
  • Safe during all trimesters 1, 2
  • Used by 40-65% of pregnant women 1
  • FDA label indicates consulting a healthcare professional before use 2

Second-Line Treatments for Acute Attacks

When acetaminophen is insufficient, consider:

• Metoclopramide

  • Safe during all trimesters
  • Particularly useful when nausea is prominent 1

• NSAIDs (second trimester only)

  • Ibuprofen: 400-800 mg every 6 hours
  • Naproxen: 275-550 mg every 2-6 hours
  • Important caveat: Avoid in third trimester due to risk of premature closure of the ductus arteriosus 1, 3

• Sumatriptan

  • Use with caution and only when other treatments fail
  • May not be associated with adverse fetal effects, but limited data 1, 4
  • Should be considered only after other options have failed 5

Preventive Treatment

Preventive treatment should only be initiated when:

• Patient experiences at least three prolonged, debilitating attacks per month
• Attacks don't respond to symptomatic therapy
• Attacks are likely to result in complications 1, 4

Preventive Medication Options:

1. First choice: Propranolol

   • Dosage: 80-160 mg once or twice daily (extended-release)
   • Best safety profile during pregnancy 1

2. Second choice: Amitriptyline

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

Important Warnings and Considerations

• Medication overuse headache risk: The American College of Physicians warns about medication overuse headache with frequent use of acute medications (headache occurring ≥15 days/month for ≥3 months) 1

• Avoid topiramate: Associated with higher rates of fetal abnormalities 1

• New-onset headaches: Especially with hypertension, should be evaluated for preeclampsia 1

• Persistent headaches with visual symptoms: Consider idiopathic intracranial hypertension 1

• Migraine with aura: Women with this condition should avoid combined hormonal contraceptives due to increased stroke risk 1

• Postpartum considerations:

  • Many women experience recurrence of migraines postpartum 5
  • Ibuprofen and sumatriptan are considered safe during breastfeeding
  • Propranolol is the first choice if preventive medication is required during breastfeeding 1

Treatment Algorithm

1. Start with non-pharmacological approaches for all patients
2. For acute attacks, use acetaminophen 1000 mg as first-line
3. If insufficient relief:
   • Add metoclopramide for attacks with prominent nausea
   • Consider NSAIDs in second trimester only
   • Reserve sumatriptan for refractory cases
4. For prevention (only if ≥3 severe attacks/month):
   • Propranolol as first choice
   • Amitriptyline as second choice if propranolol contraindicated