What are the recommended treatments for migraines in the third trimester of pregnancy?

Management of Migraines in the Third Trimester of Pregnancy

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

First-Line Treatment Options

• Paracetamol (acetaminophen) is the safest and preferred first-line pharmacological treatment for migraine attacks during the third trimester due to its established safety profile in pregnancy 1, 2
• Non-pharmacological approaches should always be implemented alongside medication, including:
  • Maintaining adequate hydration 1
  • Following regular meal schedules 1
  • Ensuring sufficient and consistent sleep patterns 1
  • Engaging in appropriate physical activity 1
  • Identifying and avoiding personal migraine triggers 1

Second-Line Treatment Options

• Metoclopramide can be used for nausea associated with migraine, particularly in the third trimester 1, 3
• Sumatriptan may be considered for sporadic use under strict specialist supervision when other treatments fail to provide adequate relief 1, 4
• NSAIDs such as ibuprofen should be avoided during the third trimester due to risks of premature closure of the ductus arteriosus and other complications 1, 4

Medications to Avoid in Third Trimester

• Opioids and butalbital-containing medications should not be used due to risks of dependency, rebound headaches, and potential harm to the fetus 1, 5
• Ergot alkaloids (including dihydroergotamine) are contraindicated during pregnancy 1, 6
• CGRP antagonists (gepants) should be avoided due to insufficient safety data in pregnancy 1
• Topiramate, candesartan, and sodium valproate are contraindicated due to known adverse effects on the fetus 1

Preventive Treatment Considerations

• Preventive medications should only be considered in cases of frequent and severely disabling migraine attacks that are unresponsive to acute treatments 1, 7
• If preventive therapy is absolutely necessary:
  • Propranolol has the best available safety data and is the first choice for preventive therapy 1, 3
  • Amitriptyline can be used if propranolol is contraindicated or ineffective 1, 7
• Regular monitoring is essential when using any preventive medications during pregnancy 1

Important Clinical Considerations

• Medication overuse headache can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1
• The majority of women experience improvement in migraine symptoms during pregnancy, particularly in the second and third trimesters 2, 3
• Treatment decisions should balance the risks of inadequately treated severe migraine (which can lead to dehydration, poor nutrition, and stress) against potential medication risks 4
• Postpartum, many women experience a recurrence of migraines, likely due to hormonal fluctuations 2

Treatment Algorithm for Third Trimester Migraine

1. Start with non-pharmacological approaches for all patients 1
2. For mild to moderate attacks: paracetamol 1000 mg 1
3. For inadequate response: add metoclopramide for associated nausea 1, 3
4. For severe, refractory attacks: consider sumatriptan under specialist supervision 1, 4
5. For frequent, disabling attacks: consider preventive therapy with propranolol or amitriptyline 1, 7