What are the recommended treatments for headaches during pregnancy?

Treatment of Headaches During Pregnancy

Paracetamol (acetaminophen) is the first-line medication for treating headaches during pregnancy due to its established safety profile. 1, 2

First-Line Treatment Options

• Paracetamol (acetaminophen) at a dose of 1000 mg is the safest first-line medication for acute treatment of headaches during pregnancy 1, 3
• Before initiating any pharmacological treatment, explore modifiable triggers and lifestyle interventions such as staying hydrated, maintaining regular sleep patterns, and engaging in appropriate physical activity 4, 1
• Non-pharmacological therapies should be tried first, including relaxation techniques, sleep hygiene, massage, ice packs, and biofeedback 3, 5

Second-Line Treatment Options

• NSAIDs such as ibuprofen can be used as a second-line option but only during the second trimester and should be avoided in the third trimester 1, 3
• Metoclopramide can be used for headaches associated with nausea during pregnancy, particularly in the second and third trimesters 1, 3
• Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail, with most safety data available specifically for sumatriptan 1, 6

Preventive Treatment

• Preventive medications should generally be avoided during pregnancy due to potential fetal harm 1, 7
• If preventive therapy is absolutely necessary due to frequent and disabling attacks, propranolol has the best available safety data and is the first choice 1, 7
• Amitriptyline can be considered if propranolol is contraindicated 1
• Topiramate, candesartan, and sodium valproate are contraindicated due to adverse effects on the fetus 1

Medications to Avoid During Pregnancy

• Ergotamine derivatives and dihydroergotamine are contraindicated during pregnancy 1, 6
• CGRP antagonists (gepants) have insufficient safety data in pregnancy and should be avoided 1
• Opioids and butalbital-containing medications should be limited due to risks of dependency and medication-overuse headache 1, 8

Special Considerations

• Headaches in pregnancy can be a symptom of serious conditions like preeclampsia, especially when accompanied by hypertension 4, 5
• A new headache in a pregnant woman with hypertension should be considered part of preeclampsia until proven otherwise 4
• Medication overuse headache can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 8
• Regular monitoring is essential when medications are used during pregnancy, especially for preventive treatments 1

Treatment Algorithm

1. Start with non-pharmacological approaches (relaxation, sleep hygiene, hydration) 3, 5
2. If medication is needed, use paracetamol (acetaminophen) as first-line treatment 1, 2
3. For second trimester only, consider NSAIDs if paracetamol is ineffective 1, 3
4. For nausea, add metoclopramide in second and third trimesters 1, 3
5. For severe, refractory headaches, consider sumatriptan under specialist supervision 1, 6
6. For prevention in cases of frequent, disabling attacks, consider propranolol 1, 7

Red Flags Requiring Urgent Evaluation

• New onset headache in pregnancy, especially with hypertension 4, 5
• Headache with focal neurological symptoms or signs 5
• Sudden onset severe headache ("thunderclap" headache) 5
• Headache with fever or neck stiffness 9
• Headache that changes with position (may indicate increased intracranial pressure) 5