What medication is recommended for migraines during pregnancy?

Migraine Medications During Pregnancy

Paracetamol (acetaminophen) is the first-line medication for acute treatment of migraine during pregnancy despite its relatively poor efficacy. 1

Acute Treatment Options

First-Line Treatment

• Paracetamol (acetaminophen) 1000 mg is the safest and preferred medication for acute migraine attacks throughout pregnancy 1
• Non-pharmacological approaches should always be tried first and used to complement any drug treatment (relaxation, sleep, massage, ice packs, biofeedback) 2, 3

Second-Line Options (with restrictions)

• NSAIDs such as ibuprofen can be used ONLY during the second trimester 1
• NSAIDs must be avoided during first and third trimesters due to specific risks 1, 2
• Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail 1, 2
  • Most safety data for triptans during pregnancy relate to sumatriptan specifically 1
  • FDA pregnancy category C - should be used only if potential benefit justifies potential risk 4

For Associated Symptoms

• Metoclopramide can be used for nausea associated with migraine in pregnancy 1, 5
• Prochlorperazine is unlikely to be harmful for treatment of nausea 5

Preventive Treatment

General Approach

• Preventive migraine medications are best avoided during pregnancy due to potential fetal harm 1
• Should only be considered in cases of frequent and disabling migraine attacks 1, 6

If Prevention Is Necessary

• Propranolol has the best available safety data and is the first choice for preventive therapy 1, 7
• Amitriptyline can be used if propranolol is contraindicated 1
• Both preventive medications should be used under specialist supervision to monitor potential fetal harm 1

Contraindicated Preventive Medications

• Topiramate is contraindicated due to adverse effects on the fetus 1
• Candesartan is contraindicated due to adverse effects on the fetus 1
• Sodium valproate is absolutely contraindicated as it is known to be teratogenic 1

Post-Partum Period

• Paracetamol remains the preferred acute medication 1
• Ibuprofen and sumatriptan are considered safe during breastfeeding 1
• If preventive medication is required postpartum, propranolol is recommended as it has the best safety profile 1

Important Clinical Considerations

• Migraine often improves during pregnancy, particularly in the second and third trimesters (60-70% of women experience improvement) 2, 7
• Women with menstrual migraine are more likely to experience improvement during pregnancy 7
• Balance risks carefully - untreated severe migraines with nausea, vomiting, and dehydration may pose greater risks to mother and fetus than judicious medication use 6
• Regular monitoring is essential when medications are used during pregnancy, especially for preventive treatments 1