What is the recommended treatment for migraines in pregnant women presenting to the emergency department (ED)?

Emergency Department Treatment of Migraine in Pregnancy

For pregnant women presenting to the ED with migraine, administer acetaminophen 1000 mg as first-line treatment, with metoclopramide for associated nausea, and reserve sumatriptan for severe refractory cases under specialist guidance. 1, 2

Immediate Assessment Priorities

Before initiating treatment, rule out preeclampsia in any pregnant woman presenting with headache and hypertension—this is preeclampsia until proven otherwise and requires urgent evaluation. 1 New-onset headache in pregnancy, particularly with hypertension, demands immediate workup rather than routine migraine treatment. 1

First-Line Acute Treatment

• Acetaminophen (paracetamol) 1000 mg is the safest and preferred first-line medication throughout all trimesters of pregnancy. 1, 2
• The American College of Obstetricians and Gynecologists specifically recommends this dose due to its relatively safe profile across pregnancy. 2
• Acetaminophen can be administered orally or as a suppository for better absorption if vomiting is present. 3

Management of Nausea and Vomiting

• Metoclopramide is safe and effective for migraine-associated nausea during pregnancy, particularly in the second and third trimesters. 1, 2
• Prochlorperazine can also be used for nausea without significant harm during pregnancy. 3
• Consider nonoral routes if severe vomiting prevents oral medication absorption. 4

Second-Line Options by Trimester

Second Trimester Only:

• NSAIDs such as ibuprofen can be used as second-line treatment, but ONLY during the second trimester. 1, 2
• NSAIDs must be avoided in the first and third trimesters due to specific fetal risks. 2, 5
• If used, limit to episodic use rather than prolonged courses. 3

Refractory Cases:

• Sumatriptan may be used sporadically under strict specialist supervision when acetaminophen and appropriate second-line options fail. 1, 2
• Among triptans, sumatriptan has the most safety data in pregnancy, though it should still be reserved for severe cases. 2, 5
• Other triptans have less safety data and should be avoided. 4

Medications to Absolutely Avoid

• Do not use opioids or butalbital-containing medications—these carry risks of dependency, rebound headaches, and potential fetal harm. 4, 1, 2
• Ergotamine derivatives and dihydroergotamine are contraindicated during pregnancy. 1, 2
• CGRP antagonists (gepants) have insufficient safety data and should be avoided. 1, 2
• Avoid aspirin and other NSAIDs in the first and third trimesters. 5, 3

Critical Pitfalls to Avoid

• Medication overuse headache can develop with frequent acute treatment (≥15 days/month with NSAIDs; ≥10 days/month with triptans). 1, 2
• Do not assume all headaches in pregnancy are benign migraine—always consider secondary causes, especially preeclampsia. 1
• Avoid prescribing preventive medications like topiramate, candesartan, or sodium valproate, which are teratogenic. 1, 2

ED Discharge Planning

• Counsel on lifestyle modifications: adequate hydration, regular meals, consistent sleep patterns, and identifying/avoiding migraine triggers. 4, 1, 2
• If migraines are frequent (≥3 severe attacks per month), refer to neurology or maternal-fetal medicine for consideration of preventive therapy with propranolol, which has the best safety profile. 1, 2
• Provide clear return precautions for signs of preeclampsia (new hypertension, visual changes, right upper quadrant pain). 1
• Ensure follow-up with obstetrics for ongoing pregnancy care and headache monitoring. 2