Migraine Management During Pregnancy

Paracetamol (acetaminophen) is the first-line medication for acute treatment of migraine during pregnancy, with a recommended dose of 1000 mg. 1

Acute Treatment Options

Paracetamol (acetaminophen) is the safest and most recommended first-line treatment for migraine attacks during pregnancy, preferably as a 1000 mg dose 1, 2
For nausea associated with migraine, metoclopramide can be used, particularly in the second and third trimesters 1, 3
NSAIDs such as ibuprofen may be used as second-line options, but only during the second trimester and should be avoided in the first and third trimesters due to specific risks 1, 4
When other treatments fail, sumatriptan may be used sporadically under strict specialist supervision, as it has the most safety data among triptans 1, 5
Prochlorperazine can be considered for treatment of migraine-associated nausea as it is unlikely to be harmful during pregnancy 2

Non-pharmacological approaches should always be tried first before considering preventive medications during pregnancy 1, 4
Preventive medications should only be considered in cases of frequent (≥3 per month) and disabling migraine attacks that are unresponsive to acute treatments 1, 3
Propranolol has the best available safety data and is the first choice for preventive therapy when needed 1, 6
Amitriptyline can be used as an alternative if propranolol is contraindicated 1, 3
Topiramate, candesartan, and sodium valproate are contraindicated due to their adverse effects on the fetus 1
CGRP antagonists (gepants) and ergot alkaloids have insufficient safety data in pregnancy and should be avoided 1

Lifestyle modifications should be the initial focus of migraine management during pregnancy 1, 5
Staying well hydrated, maintaining regular meals, ensuring sufficient sleep, and engaging in regular physical activity are important non-pharmacological strategies 1
Relaxation techniques, massage, ice packs, and biofeedback should be tried before resorting to medications 2, 4
Identifying and avoiding personal migraine triggers is crucial for effective management 1

Migraine often improves during pregnancy, with 60-70% of women experiencing remission or significant improvement, particularly during the second and third trimesters 6, 5
Women with migraine onset at menarche and those with perimenstrual migraine are more likely to experience improvement during pregnancy 6
Opioids and butalbital should be avoided for treating acute migraine during pregnancy due to associated risks 1
Medication overuse headache can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1
Regular monitoring is essential when medications are used during pregnancy, especially for preventive treatments 1

Paracetamol remains the preferred acute medication during breastfeeding 1
Ibuprofen and sumatriptan are considered safe options during breastfeeding 1
Propranolol is recommended if preventive medication is required postpartum 1
Many women experience a recurrence of migraines postpartum, likely due to the drop in estradiol and endorphin levels 5