What is the recommended management for hypertension and migraine in pregnancy?

Management of Hypertension and Migraine in Pregnancy

For pregnant women with hypertension and migraine, first-line treatment includes methyldopa or labetalol for hypertension, and acetaminophen for acute migraine attacks, with non-pharmacological approaches as foundational management for both conditions.

Hypertension Management in Pregnancy

Classification of Hypertension in Pregnancy

• Hypertension in pregnancy is classified as pre-existing hypertension (before 20 weeks), gestational hypertension (after 20 weeks without proteinuria), or pre-eclampsia (hypertension with proteinuria or other organ dysfunction) 1
• Transient gestational hypertension is not benign and carries approximately 20% risk of developing pre-eclampsia 1

Pharmacological Management

• For non-severe hypertension (140-159/90-109 mmHg):

  • Methyldopa is the first-line agent with the most long-term safety data in pregnancy 1, 2
  • Labetalol is an effective alternative with comparable efficacy to methyldopa 1
  • Calcium channel blockers (nifedipine) may be used as second or third-line agents 1, 3

• For severe hypertension (≥160/110 mmHg) requiring urgent treatment:

  • Intravenous labetalol is recommended as first-line treatment 1
  • Oral methyldopa or oral nifedipine are alternatives when IV access is not available 1
  • Intravenous hydralazine should be considered second-line due to higher risk of maternal hypotension and adverse perinatal effects 1

• Contraindicated antihypertensives in pregnancy:

  • ACE inhibitors, ARBs, and direct renin inhibitors are strictly contraindicated due to fetotoxicity 1
  • Topiramate should not be used due to higher rates of fetal abnormalities 1

Blood Pressure Targets

• Target blood pressure should be 140-150/90-100 mmHg in severe hypertension 1
• Avoid excessive lowering of blood pressure as it may impair uteroplacental perfusion 1

Migraine Management in Pregnancy

Assessment and Diagnosis

• Migraine often improves during pregnancy, particularly in the second and third trimesters 4, 5
• New-onset headache, severe headache, or headache with neurological symptoms requires urgent evaluation to rule out secondary causes including pre-eclampsia 5, 6
• Migraine is associated with increased risk of developing pre-eclampsia 6

Non-pharmacological Management

• Non-pharmacological approaches should be first-line for migraine management 4, 7:
  • Relaxation techniques, adequate sleep, and stress management 7
  • Biofeedback, massage, and ice packs for acute attacks 7
  • Avoidance of identified triggers 8

Pharmacological Management for Acute Attacks

• Acetaminophen (1000 mg) is the first-line treatment for acute migraine attacks 7, 8
• If acetaminophen is ineffective, triptans may be considered as second-line therapy with better safety profile than previously believed 6
• Avoid medications containing butalbital due to potential hazards 6
• Prochlorperazine may be used for nausea management 7
• Metoclopramide is acceptable during second and third trimesters 7

Preventive Treatment

• Prophylactic treatment is rarely indicated during pregnancy 7
• If needed, propranolol or metoprolol are the preferred options 7
• Peripheral nerve blocks may be considered as they have promising safety profiles 6
• Noninvasive neurostimulation devices are emerging options with favorable safety profiles 6

Multidisciplinary Approach

• Multidisciplinary communication among experienced clinicians should occur throughout pregnancy, delivery, and postpartum period 1
• Regular monitoring of blood pressure and assessment of fetal growth is essential 1
• Weight management counseling is recommended to ensure appropriate weight gain during pregnancy 1
• Increased outpatient observation may be helpful to reassure healthcare professionals and patients 1

Special Considerations

• Pre-eclampsia with pulmonary edema should be treated with nitroglycerin as the drug of choice 1
• For women with history of early-onset pre-eclampsia (<28 weeks), low-dose aspirin (75-100 mg/day) is recommended prophylactically, starting before 16 weeks gestation 1
• Calcium supplementation (at least 1g daily) may be beneficial in high-risk women 1
• Mode of delivery should not be determined solely based on hypertension or migraine history 1

Postpartum Management

• Monitor closely for worsening of both conditions in the postpartum period 4
• Migraine may worsen postpartum due to rapid decline in estrogen levels 4, 8
• Breastfeeding women have more treatment options available than pregnant women 5