What are the treatment options for headaches in pregnant patients?

Treatment Options for Headaches in Pregnant Patients

Paracetamol (acetaminophen) is the first-line treatment for headaches during pregnancy, as it is considered safe throughout all trimesters. 1

First-Line Treatment Options

Non-Pharmacological Approaches

• Always begin with non-pharmacological approaches:
  • Relaxation techniques
  • Adequate sleep hygiene
  • Ice packs
  • Avoiding known migraine triggers
  • Maintaining regular meals and hydration 1

First-Line Medication

• Paracetamol (acetaminophen) 1000 mg
  • Safe throughout all trimesters of pregnancy
  • Can be used as a first-line pharmacological option 1, 2
  • Preferably as a suppository for better absorption during acute attacks 2

Second-Line Treatment Options

NSAIDs (Use with Caution)

• NSAIDs should be used with extreme caution during pregnancy due to significant risks:
  • Avoid NSAIDs between 20-30 weeks gestation (limit dose and duration if absolutely necessary)
  • Completely avoid after 30 weeks gestation due to risk of premature closure of fetal ductus arteriosus 3
  • Can cause fetal renal dysfunction leading to oligohydramnios 3
  • If used, should be limited to the second trimester and for short durations 1, 2

Antiemetics (for Associated Nausea)

• Metoclopramide is compatible with pregnancy, especially in second and third trimesters 1, 2
• Prochlorperazine is unlikely to be harmful during pregnancy 2

Severe or Refractory Cases

For Moderate to Severe Migraine

• In cases where acetaminophen is ineffective:
  • Sumatriptan may be considered for sporadic use 4
  • However, triptans are generally contraindicated according to some guidelines 2
  • More recent evidence suggests triptans may not be associated with adverse fetal effects 5
  • Combination of metoclopramide and diphenhydramine may be more effective than codeine 5

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) is the first choice for prevention when needed 1, 6

Important Precautions

Medications to Avoid

• Ergot alkaloids (dihydroergotamine, ergotamine tartrate) are absolutely contraindicated 2
• Opioids should be avoided due to risk of dependency, though they may be used on a limited basis if absolutely necessary 1, 7
• Butalbital-containing medications should not be used 8

Monitoring Requirements

• If NSAIDs are used beyond 48 hours after 20 weeks gestation, consider ultrasound monitoring for oligohydramnios 3
• Monitor infants for unusual drowsiness or poor feeding with any medication use 1
• New-onset headaches during pregnancy, especially with hypertension, should be evaluated for preeclampsia 1

Medication Overuse Headache

• Be aware of medication overuse headache risk with frequent use of acute medications (≥15 days/month for ≥3 months) 8, 1

Treatment Algorithm

1. Start with non-pharmacological approaches
2. If medication needed, use paracetamol (acetaminophen) 1000 mg
3. If inadequate relief:
   • Before 20 weeks: Consider limited use of NSAIDs
   • After 20 weeks: Avoid NSAIDs if possible; if used, limit duration and monitor
   • After 30 weeks: Absolutely avoid NSAIDs
4. For severe cases unresponsive to above measures:
   • Consider metoclopramide for associated nausea
   • In refractory cases, sporadic use of sumatriptan may be considered
5. For frequent severe headaches, consider preventive therapy with propranolol only if benefits outweigh risks

The management of headaches during pregnancy requires careful consideration of both maternal relief and fetal safety. While most women experience improvement in migraine during pregnancy (60-70%), particularly in the second and third trimesters 6, appropriate treatment remains essential for those who continue to suffer.