What are the recommended treatments for migraines during pregnancy?

Treatment of Migraines During Pregnancy

Paracetamol (acetaminophen) is the first-line treatment for acute migraine attacks during pregnancy, with non-pharmacological approaches being the foundation of management. 1, 2

Non-Pharmacological Approaches (First-Line)

Non-pharmacological approaches should always be the foundation of migraine management during pregnancy:

• Lifestyle modifications:

  • Regular sleep schedule
  • Consistent meal times
  • Adequate hydration
  • Stress management techniques 1
  • Avoidance of identified triggers 3

• Complementary approaches:

  • Relaxation training
  • Biofeedback
  • Cognitive-behavioral therapy 1

Acute Treatment Options

When medication is necessary for acute migraine attacks during pregnancy:

1. First-line: Paracetamol (acetaminophen)

   • Safe throughout all trimesters 1, 2
   • Dosage: 650-1000 mg every 4-6 hours (maximum 4g/day) 1
   • Note: While generally safe, some studies suggest potential association with hyperkinetic disorders in children with prolonged use 4

2. Second-line options (use with caution):

   • NSAIDs (e.g., ibuprofen)

     • Can be used in first and second trimesters 2
     • Avoid in third trimester due to risk of premature closure of ductus arteriosus 2, 5
     • Limit to short-term use 5

   • Sumatriptan

     • Can be considered for sporadic use when paracetamol is ineffective 2
     • Has the most safety data among triptans during pregnancy 6

3. For severe, refractory attacks:

   • Antiemetics:

     • Metoclopramide (restricted to third trimester) 5
     • Chlorpromazine, dimenhydrinate, diphenhydramine 5

   • In extreme cases:

     • Short courses of corticosteroids (dexamethasone, prednisone) 5

Preventive Treatment

Preventive treatment should only be considered for severe, frequent migraines that significantly impact maternal health:

1. First-line preventive options:

   • Beta-blockers (e.g., propranolol)

     • Low doses can be used with careful monitoring 6
     • Avoid in women with asthma, heart failure, or depression 1

   • Amitriptyline

     • Low doses can be considered 6

2. Medications to avoid during pregnancy:

   • Valproate - Absolutely contraindicated due to high teratogenicity risk 1
   • Topiramate - Associated with teratogenic effects 1

Special Considerations

• First trimester: Highest risk period for teratogenicity; minimize medication use when possible
• Second and third trimesters: Many women (60-70%) experience improvement in migraine symptoms 5, 7
• Women with menstrual migraines or migraines without aura: More likely to experience improvement during pregnancy 5, 7
• Women with migraine with aura: May experience worsening during pregnancy 5

Breastfeeding Considerations

• Paracetamol remains first-line during lactation 1
• Ibuprofen is considered safe during breastfeeding 1
• Sumatriptan is compatible with breastfeeding but should be used with caution 1

Monitoring and Follow-up

• Use a headache diary to track frequency, severity, triggers, and response to treatment 3
• Evaluate treatment efficacy after 4-6 weeks 1
• Monitor for medication overuse headache, which can complicate management 1

Remember that untreated severe migraines during pregnancy can potentially lead to complications including dehydration, poor nutrition, and increased stress, which may negatively impact maternal and fetal health 4. Therefore, appropriate treatment is important while minimizing potential medication risks.