What is the recommended treatment for migraines in a pregnant woman at 20 weeks gestation?

Treatment of Migraine in Pregnancy at 20 Weeks Gestation

Paracetamol (acetaminophen) is the first-line medication for acute treatment of migraine during pregnancy at 20 weeks gestation, with a recommended dose of 1000 mg. 1

Acute Treatment Options

• Paracetamol (acetaminophen) should be used as the primary treatment due to its established safety profile throughout pregnancy 1, 2, 3
• NSAIDs such as ibuprofen can be used as a second-line option since the patient is in the second trimester (20 weeks), but should not be used for prolonged periods 1, 2
• Sumatriptan may be considered for sporadic use under specialist supervision when other treatments fail, particularly in severe cases unresponsive to paracetamol 1, 2
• Metoclopramide can be used to manage nausea associated with migraine attacks during the second trimester 1, 4

Non-Pharmacological Approaches

• Non-pharmacological approaches should always be implemented first and used to complement any required medication 2
• Identify and avoid migraine triggers as a crucial component of effective management 1
• Maintain adequate hydration, regular meal patterns, consistent sleep schedule, and engage in appropriate physical activity 1
• Consider relaxation techniques, biofeedback, massage, and application of ice packs as complementary therapies 5

Preventive Treatment Considerations

• Preventive medications should only be considered for frequent and disabling migraine attacks (≥3 severe attacks per month) that are unresponsive to acute treatments 1, 6
• If prevention is necessary, propranolol has the best safety profile and is the first choice for preventive therapy during pregnancy 1, 4
• Amitriptyline can be considered if propranolol is contraindicated 1, 6
• Topiramate, candesartan, and sodium valproate are absolutely contraindicated due to known teratogenic effects 1
• CGRP antagonists (gepants) and ergot alkaloids should be avoided due to insufficient safety data in pregnancy 1

Medications to Avoid

• Opioids and butalbital-containing medications should be limited or avoided due to risks of dependency and rebound headaches 1
• Ergotamine and dihydroergotamine are contraindicated throughout pregnancy 5
• Avoid preventive medications when possible, as most have potential fetal risks 1, 3

Important Clinical Considerations

• Regular monitoring is essential when medications are used during pregnancy, especially for preventive treatments 1
• Be aware that medication overuse headache can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1
• The risks associated with untreated severe migraine (nausea, vomiting, dehydration) may sometimes outweigh the risks of carefully selected medication 6
• Most women (60-70%) experience improvement in migraine during pregnancy, particularly in the second and third trimesters 4, 3