What are the recommended medications for migraines in pregnant women?

Migraine Medications for Pregnant Women

Acetaminophen (paracetamol) 650-1000 mg is the first-line medication for acute migraine treatment during pregnancy, preferably as a suppository when significant nausea is present. 1, 2

Treatment Algorithm for Acute Migraine in Pregnancy

First-Line Treatment

• Acetaminophen (Paracetamol): 650-1000 mg every 4-6 hours (maximum 4g/day) 1, 2
  • Safest pharmacological option during all trimesters
  • Can be administered as suppository when nausea/vomiting is severe

Second-Line Options (if acetaminophen fails)

• NSAIDs (with caution):

  • Ibuprofen or naproxen can be used episodically in first and second trimesters 2, 3
  • AVOID NSAIDs in third trimester due to risk of premature closure of the ductus arteriosus and other complications 3

• Sumatriptan: Can be considered for sporadic use in severe cases unresponsive to acetaminophen 3

  • Limited data suggests relative safety compared to other triptans
  • Should be used only when benefits outweigh potential risks

For Nausea/Vomiting

• Metoclopramide: Acceptable during second and third trimesters 2
• Prochlorperazine: Unlikely to be harmful during pregnancy 2

Prophylactic Treatment Options

Prophylactic treatment should be reserved for severe, frequent migraines that significantly impact quality of life and do not respond to acute treatments.

• Beta-blockers: Propranolol and metoprolol are the safest options for prevention 2, 4

  • Monitor for potential fetal growth restriction with long-term use

• Amitriptyline: May be considered at low doses for refractory cases 5

  • Start at lowest effective dose and monitor closely

Non-Pharmacological Approaches (First Priority)

Non-pharmacological approaches should always be tried first and used alongside any medication:

• Trigger avoidance: Identify and avoid personal triggers
• Sleep hygiene: Regular sleep schedule
• Regular meals: Avoid skipping meals
• Hydration: Maintain adequate fluid intake
• Stress management: Relaxation techniques, biofeedback
• Physical therapies: Massage, ice packs, rest in dark quiet room

Important Considerations

• 60-70% of women experience improvement in migraine during pregnancy, particularly in the second and third trimesters 4
• Women with menstrual migraine are more likely to experience improvement 4
• CONTRAINDICATED medications during pregnancy:
  • Ergotamine derivatives
  • Most triptans (except possibly sumatriptan in severe cases)
  • Valproate/divalproex (high teratogenic risk)
  • Topiramate (teratogenic risk)

Monitoring and Follow-up

• Use a headache diary to track frequency, severity, and medication use
• Reassess treatment effectiveness regularly
• Watch for signs of medication overuse headache (use of simple analgesics >15 days/month)
• Consider consultation with neurologist/headache specialist for refractory cases

Postpartum Considerations

• Migraines often recur shortly after delivery due to rapid hormonal changes 3
• Breastfeeding may have protective effects against migraine recurrence 6
• Medication choices should be reassessed based on breastfeeding status

Remember that untreated severe migraines can negatively impact maternal well-being and potentially pregnancy outcomes, so finding safe and effective treatment is important for both mother and baby 6.