From the Guidelines
Migraines during pregnancy can be safely managed with careful selection of medications and non-medication approaches, prioritizing fetal safety and maternal well-being. The management of migraines in pregnant women requires a cautious approach due to the potential risks of medications to the fetus. For acute migraine treatment, paracetamol is recommended as the first-line medication [ 1 ], due to its relatively safe profile compared to other options. It is essential to use the lowest effective dose and avoid exceeding the recommended daily limit. If paracetamol proves insufficient, metoclopramide can be considered for nausea associated with migraine [ 1 ].
Key Considerations for Migraine Management in Pregnancy
- Avoidance of certain medications: Preventive migraine medications are best avoided during pregnancy due to potential fetal harm [ 1 ]. Specifically, topiramate, candesartan, and sodium valproate are contraindicated [ 1 ].
- Use of NSAIDs: NSAIDs can only be used during the second trimester, emphasizing the need for careful timing and consideration [ 1 ].
- Triptans: The use of triptans, such as sumatriptan, should be under strict specialist supervision due to limited safety data [ 1 ].
- Non-medication strategies: Emphasizing non-medication approaches, such as maintaining regular sleep patterns, staying hydrated, avoiding triggers, and using relaxation techniques, can provide relief without medication risks.
Preventive Measures
For women with frequent and disabling migraines, propranolol or amitriptyline may be considered under specialist supervision [ 1 ], as they have the best available safety data among preventive medications. However, the decision to use these medications must be made with caution and careful monitoring for potential fetal harm.
Post-Partum Considerations
In the post-partum period, paracetamol remains the preferred acute medication, with ibuprofen and sumatriptan also considered safe [ 1 ]. For preventive medication, propranolol is recommended as the first choice due to its safety profile [ 1 ].
From the Research
Implications of Migraine Headaches During Pregnancy
- Migraine is a common issue during pregnancy, often affected by hormonal changes, with more than half of the women experiencing improvement in or remission of migraine symptoms, particularly during the second and third trimesters 2.
- A small percentage of women may see a worsening of their migraines, especially those with migraine with aura, and some may even develop migraines for the first time during pregnancy, often in the first trimester 2.
- Postpartum, many women experience a recurrence of migraines, likely due to the drop in estradiol and endorphin levels 2.
Management of Migraine During Pregnancy
- Non-pharmacological treatments are preferred, including lifestyle modifications and avoiding known triggers 2, 3, 4, 5, 6.
- When medication is necessary, acetaminophen is the first-line treatment, with nonsteroidal anti-inflammatory drugs and triptans regarded as secondary options, though trimester-specific risks limit their use 2, 4, 5.
- Preventive treatments, if required, may include low doses of β-blockers or amitriptyline but should be used cautiously 2, 5.
Alternative Therapies for Migraine Management
- Physiotherapy, structured exercise, and relaxation techniques are effective, safe, and non-invasive interventions for managing acute migraines during pregnancy 3.
- These alternative therapies can reduce migraine frequency, severity, and duration, while improving psychosocial outcomes such as quality of life, stress levels, and sleep quality in pregnant women 3.
Risks and Considerations
- Untreated migraine can lead to preterm delivery, preeclampsia, and low birth weight infants 6.
- New or refractory headache, hypertension, and abnormal neurological signs are important "red flags" to consider during pregnancy 6.
- The safety of using certain medications, such as calcitonin gene-related peptide receptor antagonists, during pregnancy and lactation remains to be determined 6.