Safest Medications for Migraines During Pregnancy

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

First-Line Treatment Options

Paracetamol (acetaminophen) is the safest pharmacological option for acute migraine attacks during pregnancy, preferably as a 1000 mg dose 1, 2
Non-pharmacological approaches should always be tried first and used to complement any medication therapy, including relaxation techniques, sleep hygiene, massage, ice packs, and biofeedback 2, 1
Staying well hydrated, maintaining regular meals, securing sufficient sleep, and identifying/avoiding migraine triggers are crucial management strategies 1

NSAIDs such as ibuprofen can be used as a second-line option, but only during the second trimester and not for prolonged periods 1, 3
NSAIDs should be avoided during the first and third trimesters due to specific risks to the fetus 3
For nausea associated with migraine, metoclopramide can be used, particularly in the third trimester 1, 4
Prochlorperazine for nausea treatment is unlikely to be harmful during pregnancy 2

Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail 1, 3
Among triptans, sumatriptan has the most safety data in pregnancy 1, 5
In some refractory cases, short courses of corticosteroids like dexamethasone or prednisone may be considered 4

Ergotamine derivatives and dihydroergotamine are contraindicated during pregnancy 6, 2
Most triptans (except for occasional use of sumatriptan) should be avoided 2
Opioids and butalbital-containing medications should not be used due to risks of dependency, rebound headaches, and potential fetal harm 1
CGRP antagonists (gepants) and ergot alkaloids have insufficient safety data in pregnancy and should be avoided 1

Preventive migraine medications should generally be avoided during pregnancy due to potential fetal harm 1
If preventive treatment becomes necessary due to frequent and disabling attacks:
- Propranolol has the best available safety data and is the first choice 1, 2
- Amitriptyline can be used if propranolol is contraindicated 1
Topiramate, candesartan, and sodium valproate are contraindicated due to adverse effects on the fetus 1

Regular monitoring is essential when medications are used during pregnancy, especially for 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
Untreated severe migraine can potentially lead to complications including premature labor, hypertension, and low birth weight 7
Between 60-70% of women experience improvement in migraine symptoms during pregnancy, particularly in the second and third trimesters 4, 2