What are the treatment options for migraines during pregnancy?

Migraine Abortive Therapy in Pregnancy

Paracetamol (acetaminophen) 1000 mg is the first-line abortive medication for acute migraine during pregnancy, preferably as a suppository, and should be used before considering any other pharmacological options. 1, 2

Acute Treatment Algorithm

First-Line Treatment

• Paracetamol 1000 mg is recommended as the initial abortive agent due to its relatively safe profile throughout all trimesters 1, 2, 3
• The suppository formulation is preferred when available 3
• The FDA states that pregnant women should consult a health professional before use, though it remains the safest option 4

Second-Line Treatment (Trimester-Specific)

• NSAIDs (ibuprofen, naproxen) can be used ONLY during the second trimester when paracetamol fails 1, 2
• These agents must be strictly avoided in the first and third trimesters due to specific fetal risks 2, 3
• When used, limit to episodic use rather than prolonged courses 5, 3

Third-Line Treatment (Specialist Supervision Required)

• Sumatriptan may be used sporadically under strict specialist supervision when first and second-line options fail 1, 2
• Among the triptans, sumatriptan has the most safety data available 2, 6
• This should be reserved for severe, refractory cases only 6, 7

Adjunctive Medications for Nausea

• Metoclopramide can be used for migraine-associated nausea, particularly during the second and third trimesters 1, 2
• Prochlorperazine is unlikely to be harmful during pregnancy 3
• Dimenhydrinate and diphenhydramine can be considered for severe attacks 5

Medications That Are Absolutely Contraindicated

• Ergotamine derivatives and dihydroergotamine are contraindicated throughout pregnancy 1, 2
• CGRP antagonists (gepants) have insufficient safety data and should be avoided 1, 2
• Opioids and butalbital-containing medications should not be used due to risks of dependency, rebound headaches, and medication-overuse headache 1, 2
• Other triptans besides sumatriptan lack adequate safety data 3

Critical Pitfalls to Avoid

• Medication overuse headache can develop with frequent use: ≥15 days/month with NSAIDs or ≥10 days/month with triptans 1, 2
• NSAIDs in the third trimester can cause premature closure of the ductus arteriosus and other complications 2, 3
• New-onset headache with hypertension should be considered preeclampsia until proven otherwise and requires urgent evaluation 1

Non-Pharmacological Approaches (Always Try First)

Before initiating any medication, implement these strategies: 1, 2

• Maintain adequate hydration and regular meals
• Ensure sufficient and consistent sleep patterns
• Engage in appropriate physical activity
• Identify and avoid specific migraine triggers
• Consider biofeedback, relaxation techniques, massage, and ice packs 5, 3

When Severe Attacks Are Refractory

For truly refractory severe cases that fail all standard options, consider: 5

• Chlorpromazine under specialist guidance
• Short courses of dexamethasone or prednisone in extreme circumstances
• Meperidine or morphine (avoid at end of third trimester)

Important Clinical Context

The risk of untreated severe, frequent migraine attacks—including dehydration, hypotension, anorexia, and potential complications like preterm labor—may outweigh the risks of appropriate medication use 6, 8