What are the options for migraine prophylaxis (prevention) in pregnant women?

Migraine Prophylaxis Options for Pregnant Women

For migraine prophylaxis in pregnant women, non-pharmacological approaches should be first-line treatment, with low-dose propranolol (80-160 mg daily) as the safest pharmacological option when necessary. 1, 2, 3

First-Line: Non-Pharmacological Approaches

Non-pharmacological interventions should always be the first approach for migraine prophylaxis during pregnancy:

• Lifestyle modifications:

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

• Evidence-based complementary approaches:

  • Relaxation training
  • Thermal biofeedback combined with relaxation training
  • Cognitive-behavioral therapy
  • Magnesium supplements
  • Riboflavin supplements
  • Coenzyme Q10 supplements 1

Second-Line: Pharmacological Options

When non-pharmacological approaches are insufficient and prophylactic medication is necessary:

Beta-Blockers

• Propranolol: 80-160 mg once daily is the preferred pharmacological option 1, 2, 3
  • Considered relatively safe during pregnancy
  • FDA-approved for migraine prophylaxis
  • Should be used at the lowest effective dose
  • Monitor for potential fetal growth restriction with long-term use

Antidepressants

• Amitriptyline: Low doses (10-25 mg at bedtime) may be considered in severe cases 1, 4
  • Use with caution and only when benefits outweigh risks
  • Monitor for anticholinergic side effects and sedation

Medications to Avoid During Pregnancy

• Valproate/Divalproex sodium: Contraindicated due to high teratogenicity risk 1
• Topiramate: Associated with increased risk of oral clefts and low birth weight 4
• CGRP antagonists (gepants): Insufficient safety data in pregnancy 5, 1
• Ditans (lasmiditan): Insufficient safety data in pregnancy 5
• Botulinum toxin: Limited safety data in pregnancy 4

Special Considerations

• Trimester-specific approach:

  • First trimester: Highest risk for teratogenicity; minimize all medications if possible
  • Second and third trimesters: Many women experience natural improvement in migraine symptoms 6, 4

• Monitoring and follow-up:

  • Use a headache diary to track frequency, severity, triggers, and response to treatment 1
  • Regular follow-up to assess effectiveness of prophylactic measures
  • Adjust treatment as pregnancy progresses

• Postpartum considerations:

  • Migraines often recur postpartum due to hormonal fluctuations 6, 7
  • Breastfeeding may have protective effects against migraine recurrence 7
  • Different medication options may be available during lactation

Clinical Pitfalls to Avoid

• Don't undertreat: Severe, untreated migraines during pregnancy may lead to dehydration, poor nutrition, and stress, potentially affecting maternal and fetal outcomes 4

• Don't overmedicate: Use the lowest effective dose of any necessary medication

• Don't forget preconception counseling: Women with migraine should ideally receive counseling before pregnancy to develop an appropriate management plan 8, 7

• Don't neglect comorbidities: Hypertension, depression, and anxiety often coexist with migraine and require appropriate management during pregnancy

• Don't miss warning signs: New-onset migraines, especially with aura, during pregnancy may warrant further investigation to rule out secondary causes like preeclampsia