Safe Medications for Migraine During Pregnancy

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

Acute Treatment Options

Paracetamol (acetaminophen) is considered the safest first-line option for treating migraine attacks during pregnancy 1, 2, 3
NSAIDs such as ibuprofen can be used as a second-line option only during the second trimester, but should be avoided in the first and third trimesters due to specific risks 1, 3
Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail, with most safety data supporting sumatriptan specifically among the triptans 1, 3
Metoclopramide can be used for nausea associated with migraine in pregnancy, particularly during the second and third trimesters 1, 2
Prochlorperazine is unlikely to be harmful during pregnancy and can be used for migraine-associated nausea 2

Ergotamine derivatives and dihydroergotamine are contraindicated during pregnancy due to potential risks to the fetus 1, 2, 3
Topiramate, candesartan, and sodium valproate are contraindicated due to adverse effects on the fetus 1, 4
CGRP antagonists (gepants) and ergot alkaloids 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

Preventive migraine medications should be avoided during pregnancy unless absolutely necessary for frequent and disabling attacks 1, 5
If prevention is required, propranolol has the best safety profile and is the first choice for preventive therapy 1, 2, 5
Amitriptyline can be considered if propranolol is contraindicated 1, 5
Preventive treatment should only be implemented after careful risk-benefit assessment and preferably during the second and third trimesters 5, 6

Before initiating any pharmacological treatment, non-pharmacological approaches should be tried first 1, 2
Effective non-pharmacological strategies include:
- Staying well hydrated and maintaining regular meals 1
- Securing sufficient and consistent sleep patterns 1
- Engaging in appropriate physical activity 1
- Relaxation techniques, massage, ice packs, and biofeedback 2
- Identifying and avoiding migraine triggers 1

Regular monitoring is essential when medications are used during pregnancy, especially for preventive treatments 1
A new headache in a pregnant woman with hypertension should be considered part of preeclampsia until proven otherwise 1
Medication overuse headache can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1
Multidisciplinary communication among relevant experienced clinicians should occur throughout pregnancy, peridelivery, and in the postpartum period 4

Paracetamol remains the preferred acute medication during breastfeeding 1
Ibuprofen and sumatriptan are considered safe during breastfeeding 1
NSAIDs such as ibuprofen are recommended as first-line treatment for postpartum pain after vaginal delivery 7
If preventive medication is required postpartum, propranolol is recommended as it has the best safety profile 1, 7