What are the recommended treatments for headaches during pregnancy?

Management of Headaches During Pregnancy

Paracetamol (acetaminophen) is the first-line medication for treating headaches during pregnancy, with a recommended dose of 1000 mg, due to its relatively safe profile. 1

Types of Headaches in Pregnancy

• Headaches during pregnancy can be either primary (migraine, tension-type) or secondary (symptom of potentially serious conditions) 2
• Migraine is the most common type of headache complicating pregnancy, with 60-70% of women experiencing improvement during pregnancy, particularly in the second and third trimesters 3
• New headaches during pregnancy, especially with hypertension, should be considered part of preeclampsia until proven otherwise 4

First-Line Treatment Options

• Non-pharmacological approaches should always be tried first:

  • Lifestyle modifications including adequate hydration, regular meals, consistent sleep patterns, and regular physical activity 1
  • Relaxation techniques, massage, ice packs, and biofeedback 5
  • Identifying and avoiding migraine triggers 1

• When medication is necessary:

  • Paracetamol (acetaminophen) 1000 mg is the safest first-line pharmacological option 1, 5
  • Metoclopramide can be used for associated nausea, particularly in the second and third trimesters 1, 5

Second-Line Treatment Options

• NSAIDs such as ibuprofen can be used as a second-line option but only during the second trimester and should be avoided in the third trimester due to risks 1, 5
• For severe attacks resistant to first-line treatments:
  • Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail 1
  • Prochlorperazine is unlikely to be harmful during pregnancy and can effectively treat headache pain 4, 5

Medications to Avoid During Pregnancy

• Topiramate should not be used in pregnancy due to clear evidence of higher rates of fetal abnormalities 4, 1
• Ergotamine and dihydroergotamine are contraindicated during pregnancy 5
• Opioid analgesics should be limited and carefully monitored due to risks of dependency and rebound headaches 4, 1
• CGRP antagonists (gepants) should be avoided due to insufficient safety data 1

Preventive Treatment

• Preventive medications should be avoided if possible during pregnancy 1
• If prevention is necessary due to frequent and disabling attacks:
  • Propranolol has the best safety profile and is the first choice for preventive therapy 1, 3
  • Amitriptyline can be used if propranolol is contraindicated 1

Special Considerations

• For women with idiopathic intracranial hypertension (IIH) during pregnancy:
  • Multidisciplinary communication among experienced clinicians should occur throughout pregnancy 4
  • Weight management is important, with referral to appropriate services to ensure weight gain is appropriate for gestational age 4
  • For acute exacerbations with risk of vision loss, serial lumbar punctures may be considered as a temporary measure 4

Red Flags Requiring Urgent Evaluation

• New-onset headache in pregnancy, especially with hypertension 4
• Headache associated with neurological symptoms, which could indicate stroke, cerebral venous thrombosis, or subarachnoid hemorrhage 2
• Severe, sudden-onset headache ("thunderclap") 6
• Visual disturbances, especially with hypertension, which could indicate preeclampsia 4

Postpartum Considerations

• Paracetamol remains the preferred acute medication during breastfeeding 1
• Ibuprofen and sumatriptan are considered safe during breastfeeding 1
• Propranolol is recommended if preventive medication is required postpartum 1
• Migraine often recurs in the postpartum period due to rapid fall in estrogen levels 5