What is the recommended treatment for migraine in an 18-week pregnant patient?

Treatment of Migraine in an 18-Week Pregnant Patient

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

First-Line Treatment Options

• Paracetamol (acetaminophen) 1000 mg is the safest and preferred first-line treatment for acute migraine attacks during pregnancy 1, 2
• Non-pharmacological approaches should be tried concurrently with medication:
  • Relaxation techniques, adequate sleep, massage, ice packs, and biofeedback 2
  • Regular hydration, consistent meal timing, and identifying/avoiding personal migraine triggers 1

Second-Line Treatment Options

• NSAIDs such as ibuprofen can be used during the second trimester (which applies to an 18-week pregnant patient) when paracetamol is ineffective 1, 3
• NSAIDs should be used only episodically and avoided in the third trimester due to potential complications 2
• Metoclopramide can be safely used for migraine-associated nausea during the second and third trimesters 1, 2

Rescue Treatment for Refractory Cases

• Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail 1, 4
• Prochlorperazine is unlikely to be harmful during pregnancy and can be considered for severe attacks 2, 5
• Opioids should be limited and carefully monitored due to risks of dependency and rebound headaches 6, 1

Preventive Treatment Considerations

• Preventive treatment should only be considered if the patient experiences at least three severe, disabling attacks per month that are unresponsive to acute therapy 4
• If prophylaxis is necessary:
  • Propranolol has the best safety profile and is the first choice for preventive therapy during pregnancy 1, 5
  • Amitriptyline can be used if propranolol is contraindicated 1
  • Topiramate, candesartan, and sodium valproate are contraindicated due to teratogenic effects 1

Important Precautions

• Avoid medication overuse (≥15 days/month with NSAIDs; ≥10 days/month with triptans) to prevent medication-overuse headache 1
• Ergot alkaloids (ergotamine, dihydroergotamine) are absolutely contraindicated during pregnancy 2, 3
• CGRP antagonists (gepants) should be avoided due to insufficient safety data in pregnancy 1
• Regular monitoring is essential when medications are used during pregnancy, especially for preventive treatments 1

Treatment Algorithm for Migraine in Pregnancy

1. Start with paracetamol 1000 mg for acute attacks 1
2. If ineffective, consider NSAIDs (ibuprofen) as you are in the second trimester 1, 3
3. For associated nausea, add metoclopramide 1, 2
4. For severe refractory attacks, consider sumatriptan under specialist guidance 1, 4
5. If experiencing frequent disabling attacks (≥3/month), discuss propranolol for prevention 1, 5

Remember that untreated severe migraine can potentially lead to dehydration, poor nutrition, and stress, which may negatively impact pregnancy outcomes 7. Therefore, appropriate treatment is important for both maternal and fetal well-being.