What are safe medications for treating migraines in pregnant women?

Safe Medications for Treating Migraines in Pregnant Women

Paracetamol (acetaminophen) is the first-line treatment for migraine during pregnancy, with NSAIDs as second-line options in the second trimester only, and sumatriptan as a cautious alternative when other treatments fail. 1

First-Line Treatment Options

Non-Pharmacological Approaches

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

First-Line Medication

• Paracetamol (acetaminophen)
  • Dosage: 1000 mg (preferably as suppository)
  • Safety: Considered safe throughout all trimesters 1, 2
  • Very low transfer into breast milk if postpartum 1

Second-Line Treatment Options

NSAIDs (Use with caution)

• Ibuprofen

  • Dosage: 400-800 mg every 6 hours
  • Safety: Use only in second trimester 1
  • Avoid in first and third trimesters due to specific risks 1, 2

• Naproxen

  • Dosage: 275-550 mg every 2-6 hours
  • Safety: Use only in second trimester 1
  • Avoid in first and third trimesters 1, 3

For Nausea Management

• Metoclopramide

  • Safety: Acceptable during second and third trimesters 2, 4
  • Should be restricted to third trimester according to some evidence 4

• Prochlorperazine

  • Safety: Unlikely to be harmful during pregnancy 2

Third-Line Treatment Options

Triptans

• Sumatriptan
  • Use only when other treatments fail
  • Safety: Use with caution 1
  • Some evidence suggests sporadic use can be considered 3
  • Contraindicated according to older guidelines 2

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

  • Dosage: 80-160 mg once or twice daily (extended-release)
  • Safety: First choice for prevention when needed 1, 2, 4

• Metoprolol

  • Safety: Can be given during pregnancy 2

Treatment Algorithm

1. Start with non-pharmacological approaches for all pregnant women with migraine
2. If medication needed:
   • First trimester: Paracetamol only
   • Second trimester: Paracetamol first, then NSAIDs if needed
   • Third trimester: Paracetamol only
3. For severe, refractory cases:
   • Consider sumatriptan (with caution)
   • Add anti-nausea medication if needed
4. For frequent, debilitating migraines:
   • Consider propranolol for prevention

Important Cautions and Red Flags

• Avoid these medications during pregnancy:

  • Ergotamine and dihydroergotamine (contraindicated) 2
  • Aspirin (especially in third trimester) 1, 4
  • Codeine and opioids (risk of infant sedation) 1
  • Butalbital-containing medications 1, 5

• Watch for medication overuse headache:

  • Can occur with frequent use of acute medications (≥15 days/month for ≥3 months) 1

• New-onset headaches during pregnancy:

  • Especially with hypertension, should be evaluated for preeclampsia 1

• Neuroimaging is required when:

  • Headache is accompanied by focal neurologic deficits
  • Failure to respond to initial therapy
  • Altered consciousness or seizures 1

Most pregnant women (55-90%) experience improvement in migraine symptoms during pregnancy, particularly during the second and third trimesters 2, 4, 6. However, careful medication selection is essential to balance symptom relief with maternal and fetal safety.