What are the recommended treatments for managing migraine in pregnancy?

Managing Migraine in Pregnancy

Paracetamol (acetaminophen) 1000 mg is the first-line acute treatment for migraine during pregnancy, with NSAIDs like ibuprofen reserved for second-trimester use only, and preventive therapy avoided unless absolutely necessary. 1, 2

Acute Treatment Strategy

First-Line Treatment

• Paracetamol (acetaminophen) 1000 mg is the preferred acute medication throughout all trimesters of pregnancy due to its relatively safe profile 1, 2
• This should be the initial pharmacological approach after non-pharmacological measures fail 2

Second-Line Options

• NSAIDs such as ibuprofen can be used only during the second trimester as a second-line option when paracetamol is insufficient 1, 2
• NSAIDs must be avoided in the first and third trimesters due to specific fetal risks 2
• Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail, with sumatriptan having the most safety data among triptans 1, 2

Adjunctive Treatment for Nausea

• Metoclopramide can be used for migraine-associated nausea, particularly during the second and third trimesters 1, 2
• Consider nonoral routes if severe vomiting prevents oral medication absorption 1

Medications That Must Be Avoided

Absolutely Contraindicated

• Ergotamine derivatives and dihydroergotamine are contraindicated due to potential fetal harm 2
• Topiramate, candesartan, and sodium valproate are contraindicated due to adverse fetal effects 1, 2
• CGRP antagonists (gepants) have insufficient safety data and should be avoided 2

Should Be Limited or Avoided

• Opioids and butalbital-containing medications should not be used due to risks of dependency, rebound headaches, and potential fetal harm 1, 2
• These medications carry significant risks that outweigh benefits in migraine management 1

Preventive Treatment Approach

General Principle

• Preventive medications should be avoided during pregnancy unless absolutely necessary for frequent and disabling attacks 1, 2
• Consider preventive therapy only when patients experience at least three prolonged severe attacks monthly that are particularly incapacitating or unresponsive to acute therapy 3

When Prevention Is Required

• Propranolol has the best safety data and is the first choice for preventive therapy during pregnancy 1, 2
• Amitriptyline can be used if propranolol is contraindicated 1, 2
• Regular monitoring is essential when any preventive medications are used during pregnancy 2

Non-Pharmacological Management

Lifestyle Modifications (Always First-Line)

• Staying well hydrated and maintaining regular meals are fundamental interventions 1, 2
• Securing sufficient and consistent sleep patterns helps prevent migraine attacks 1, 2
• Engaging in appropriate physical activity provides preventive benefits 1, 2
• Identifying and avoiding migraine triggers is crucial for effective management 1, 2

Environmental Modifications

• Providing a quiet, dark environment can be beneficial during acute attacks 1
• Ensuring adequate hydration with IV fluids may be necessary in severe cases 1

Critical Safety Considerations

Medication Overuse Headache

• Medication overuse headache can occur with ≥15 days/month of NSAID use or ≥10 days/month of triptan use 1, 2
• This represents a common pitfall that can worsen the overall headache burden 1

Red Flags Requiring Urgent Evaluation

• A new headache in a pregnant woman with hypertension should be considered preeclampsia until proven otherwise 1
• New onset headache in pregnancy, especially with hypertension, requires urgent evaluation 1
• Before treating headaches in patients not previously diagnosed as migraineurs, exclude other potentially serious neurological conditions 4

Postpartum and Breastfeeding Period

Acute Treatment

• Paracetamol remains the preferred acute medication during breastfeeding 1, 2
• Ibuprofen and sumatriptan are considered safe during breastfeeding 1, 2
• NSAIDs such as ibuprofen are recommended as first-line treatment for postpartum pain after vaginal delivery 2

Preventive Treatment

• If preventive medication is required postpartum, propranolol is recommended as it has the best safety profile 1, 2

Emergency Department Considerations

Severe Refractory Cases

• In cases of severe, refractory migraine, corticosteroids like dexamethasone or prednisone can be considered in consultation with obstetrics, but only after other options have failed 1
• Avoid traditional "migraine cocktail" components like NSAIDs, triptans, and opioids in pregnant patients 1

Discharge Planning

• Prescribe acetaminophen 1000 mg for home use rather than opioids or butalbital-containing rescue medications 1
• Counsel on lifestyle modifications including adequate hydration, regular meals, consistent sleep patterns, and trigger avoidance 1