What are the recommended management strategies for migraines during pregnancy?

Management of Migraine During Pregnancy

Paracetamol (acetaminophen) is the first-line medication for acute migraine treatment during pregnancy due to its established safety profile. 1, 2, 3

Non-Pharmacological Approaches

• Always begin with non-pharmacological interventions before considering medications, including:
  • Identifying and avoiding migraine triggers 1
  • Maintaining adequate hydration and regular meal patterns 1
  • Ensuring sufficient and consistent sleep 1
  • Engaging in appropriate regular physical activity 1
  • Relaxation techniques, biofeedback, and massage 4

Acute Treatment Algorithm

1. First-line treatment:

   • Paracetamol (acetaminophen) 1000 mg (oral or suppository) 1, 2, 3

2. Second-line options (if paracetamol is ineffective):

   • NSAIDs such as ibuprofen - ONLY during second trimester, avoid in first and third trimesters due to specific risks 1, 2, 3
   • Sumatriptan - can be used sporadically under specialist supervision when other treatments fail 1, 2

3. For associated nausea:

   • Metoclopramide - safest in second and third trimesters 1, 5
   • Dimenhydrinate or diphenhydramine can be used for severe attacks 5

Preventive Treatment

Preventive medications should only be considered for frequent and disabling migraine attacks that significantly impact maternal health and quality of life 1, 3.

Preventive treatment hierarchy:

1. First choice: Propranolol - has the best available safety data 1, 6, 4
2. Second choice: Amitriptyline - if propranolol is contraindicated 1, 3, 6

Medications to Avoid During Pregnancy

• Absolutely contraindicated:

  • Topiramate, candesartan, and sodium valproate - known teratogenic effects 1
  • CGRP antagonists (gepants) - insufficient safety data 1
  • Ergot alkaloids - contraindicated 1, 4

• Use with extreme caution:

  • Opioids and butalbital-containing medications - risk of dependency, rebound headaches, and potential fetal harm 1

Post-Partum and Breastfeeding Considerations

• Migraines often recur shortly after delivery due to hormonal fluctuations 2, 3
• During breastfeeding:
  • Paracetamol remains the preferred acute medication 1
  • Ibuprofen and sumatriptan are considered safe during breastfeeding 1
  • Propranolol is recommended if preventive medication is required 1

Important Clinical Considerations

• Regular monitoring is essential when medications are used during pregnancy, especially preventive treatments 1
• Medication overuse headache can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1
• Between 60-70% of women experience improvement in migraine during pregnancy, particularly in the second and third trimesters 3, 5
• Women with menstrual migraines or migraines without aura tend to benefit most from pregnancy-related improvement 3, 5
• A small percentage (4-8%) may experience worsening migraines during pregnancy, with migraine with aura being overrepresented in this group 5