What are the recommended treatments for migraines during pregnancy?

Migraine Treatment in Pregnancy

Paracetamol (acetaminophen) is the first-line medication for acute treatment of migraine during pregnancy at a recommended dose of 1000 mg due to its relatively safe profile. 1

Acute Treatment Options

First-Line Treatment

• Paracetamol (acetaminophen) is the safest option for acute migraine attacks throughout pregnancy 1, 2
• Non-pharmacological approaches should always be tried first, including relaxation techniques, sleep, massage, ice packs, and biofeedback 1, 3

Second-Line Treatment

• NSAIDs such as ibuprofen can be used only during the second trimester and should be avoided in the first and third trimesters due to specific risks 1, 4
• Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail, with most safety data available specifically for sumatriptan 1, 4

For Associated Symptoms

• Metoclopramide can be used for migraine-associated nausea, especially in the third trimester 1, 5
• Prochlorperazine is unlikely to be harmful during pregnancy and can help with nausea 3

Preventive Treatment

When to Consider Prevention

• Preventive medications should only be considered in cases of frequent and disabling migraine attacks (at least three prolonged severe attacks per month) that are particularly incapacitating or unresponsive to symptomatic therapy 1, 2

Preventive Options

• Propranolol has the best available safety data and is the first choice for preventive therapy during pregnancy 1, 5
• Amitriptyline can be used if propranolol is contraindicated 1, 2
• Topiramate, candesartan, and sodium valproate are contraindicated due to adverse effects on the fetus 1

Important Clinical Considerations

Medication Overuse

• Be aware of medication overuse headache, which can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 6
• Regular monitoring is essential when medications are used during pregnancy, especially for preventive treatments 1

Lifestyle Modifications

• Highlight the importance of staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, and engaging in regular physical activity 6
• Stress management with relaxation techniques or mindfulness practices can be particularly helpful during pregnancy 6, 1

Post-Partum Period

• Paracetamol remains the preferred acute medication during breastfeeding 1
• Ibuprofen and sumatriptan are considered safe during breastfeeding 1, 4
• If preventive medication is required postpartum, propranolol is recommended as it has the best safety profile 1

Treatment Algorithm

1. Start with non-pharmacological approaches:

   • Relaxation techniques, adequate sleep, hydration, regular meals 1, 3
   • Identify and avoid migraine triggers 6

2. For acute attacks requiring medication:

   • First-line: Paracetamol 1000 mg 1, 2
   • Second-line (if paracetamol ineffective):
     • Second trimester only: NSAIDs such as ibuprofen 1, 4
     • For severe, refractory attacks: Sumatriptan under specialist supervision 1, 4

3. For nausea and vomiting:

   • Metoclopramide (especially in third trimester) 1, 5
   • Prochlorperazine as an alternative 3

4. For prevention (only if experiencing ≥3 severe attacks monthly):

   • First-line: Propranolol 1, 5
   • Alternative: Amitriptyline if propranolol is contraindicated 1, 2

Cautions and Contraindications

• Avoid opioids and butalbital for the treatment of acute migraine 6
• Topiramate, candesartan, and sodium valproate are contraindicated in pregnancy 1, 6
• NSAIDs should be avoided in the first and third trimesters 1, 4
• CGRP antagonists (gepants) and ergot alkaloids have insufficient safety data in pregnancy and should be avoided 6, 4