What are the recommended treatments for migraines in pregnant and breastfeeding women?

Treatment of Migraines in Pregnant and Breastfeeding Women

Paracetamol (acetaminophen) is the first-line medication for acute migraine treatment in pregnant women, while non-pharmacological approaches should always be used as initial management and to complement any required drug treatment. 1

Acute Treatment During Pregnancy

First-line Treatment

• Paracetamol (acetaminophen): 1000 mg as needed 2, 1
  • Safe in all trimesters of pregnancy
  • First choice for acute migraine attacks

Second-line Options (use with caution)

• NSAIDs (only in second trimester):

  • Ibuprofen: 400-800 mg every 6 hours 1
  • Naproxen: 275-550 mg every 2-6 hours 1
  • Avoid NSAIDs in first and third trimesters due to risk of:
    • First trimester: Possible increased risk of miscarriage
    • Third trimester: Premature closure of ductus arteriosus 3

• Sumatriptan: Consider only when other treatments fail 1

  • FDA Pregnancy Category C 4
  • Use with caution and only if benefit justifies risk 4
  • Some evidence suggests it may not be associated with adverse fetal effects 1

• Metoclopramide: Can be used for nausea, especially in second and third trimesters 1

Contraindicated Medications

• Ergotamine derivatives (absolute contraindication)
• Topiramate (associated with higher rates of fetal abnormalities) 1

Preventive Treatment During Pregnancy

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.

Preferred Options

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

   • Best safety profile during pregnancy
   • First choice for prevention when needed

2. Amitriptyline: 10-100 mg at night 1

   • Second choice if propranolol is contraindicated
   • Requires specialist supervision

Treatment During Breastfeeding

Acute Treatment

• Paracetamol (acetaminophen): Remains the preferred acute medication 1
• Ibuprofen: Considered safe during breastfeeding 1
• Sumatriptan: Safe during breastfeeding, but avoid breastfeeding for 12 hours after administration to minimize infant exposure 1, 4

Preventive Treatment

• Propranolol: First choice if preventive medication is required during breastfeeding 1

Non-Pharmacological Approaches

These should always be first-line and used to complement any required drug treatment 1:

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

Special Considerations

• New-onset headaches during pregnancy, especially with hypertension, should be evaluated for preeclampsia 1
• Persistent headaches with visual symptoms should be considered for idiopathic intracranial hypertension 1
• Women with migraine with aura should avoid combined hormonal contraceptives due to increased stroke risk 1

Treatment Algorithm

1. Start with non-pharmacological approaches for all pregnant and breastfeeding women
2. If acute medication needed:
   • First choice: Paracetamol 1000 mg
   • Second choice (pregnancy):
     • Second trimester only: NSAIDs (ibuprofen/naproxen)
     • Any trimester if severe and unresponsive: Sumatriptan (with caution)
   • Second choice (breastfeeding): Ibuprofen or sumatriptan
3. If preventive treatment needed:
   • First choice: Propranolol
   • Second choice: Amitriptyline (with specialist supervision)

Remember that most women (60-70%) experience improvement in migraine symptoms during pregnancy, particularly in the second and third trimesters 5, but careful medication selection is essential when treatment is required.