What are the safest treatment options for headaches during pregnancy?

Treatment of Headaches During Pregnancy

Acetaminophen (paracetamol) 1000 mg is the first-line treatment for headaches during pregnancy, with NSAIDs like ibuprofen reserved as second-line only during the second trimester. 1

Acute Treatment Algorithm

First-Line Therapy

• Acetaminophen 1000 mg is the safest acute treatment option throughout all trimesters of pregnancy 1, 2
• Preferably administered as a suppository for better absorption, particularly if nausea is present 2
• Can be used for both migraine and tension-type headaches 3

Second-Line Options

• NSAIDs (ibuprofen, naproxen) may be used during the second trimester only 1, 2
• Must be strictly avoided in the third trimester due to risks of premature closure of the ductus arteriosus and other fetal complications 2, 4
• Should not be used chronically even when permitted 2

Third-Line for Refractory Cases

• Sumatriptan may be considered sporadically under strict specialist supervision when other treatments fail 1
• Among triptans, sumatriptan has the most safety data and may not be associated with fetal/child adverse effects 3
• However, all triptans were historically listed as contraindicated in older guidelines 5, 2

Adjunctive Therapy for Nausea

• Metoclopramide is safe and effective for migraine-associated nausea, particularly in the second and third trimesters 1, 4
• Prochlorperazine is unlikely to be harmful during pregnancy 2
• Consider nonoral routes if severe vomiting prevents oral medication absorption 1

Medications to Strictly Avoid

Absolutely Contraindicated

• Ergotamine and dihydroergotamine are contraindicated due to uterotonic effects 5, 1, 2
• Opioids and butalbital-containing medications should not be used due to risks of dependency, rebound headaches, and potential fetal harm 1, 6
• Topiramate, candesartan, and sodium valproate are contraindicated due to teratogenic effects 1
• CGRP antagonists (gepants) have insufficient safety data and should be avoided 1

Medication Overuse Headache Risk

• Can occur with frequent use: ≥15 days/month with NSAIDs or ≥10 days/month with triptans 1, 6

Preventive Treatment (Rarely Indicated)

Preventive medications should be avoided during pregnancy unless migraine attacks are frequent and severely disabling. 1

• Propranolol has the best safety data and is first choice if preventive therapy is absolutely necessary 1, 2, 4
• Metoprolol is an alternative beta-blocker option 2
• Amitriptyline can be used if propranolol is contraindicated, though it may be associated with some fetal/child adverse effects 1, 3

Non-Pharmacological Interventions (Always First-Line)

Before initiating pharmacological treatment, implement lifestyle modifications: 1

• Maintain adequate hydration 1
• Ensure regular meals and consistent sleep patterns 1
• Engage in regular physical activity 1
• Identify and avoid migraine triggers 1
• Consider relaxation techniques, biofeedback, massage, and ice packs 2, 4

Critical Red Flags Requiring Urgent Evaluation

• New headache in a pregnant woman with hypertension should be considered preeclampsia until proven otherwise 1
• This requires urgent blood pressure assessment and evaluation for end-organ damage 1
• New onset headache in pregnancy, especially with hypertension, warrants immediate evaluation 1

Postpartum and Breastfeeding Considerations

• Acetaminophen remains the preferred acute medication 1
• Ibuprofen and sumatriptan are considered safe during breastfeeding 1, 7
• NSAIDs like ibuprofen are first-line for postpartum pain after vaginal delivery 6
• If preventive medication is required postpartum, propranolol has the best safety profile 1, 6

Emergency Department Management

For severe, refractory migraine in the ED: 1

• Provide a quiet, dark environment and ensure adequate IV hydration 1
• Use metoclopramide for nausea via nonoral routes if needed 1
• In consultation with obstetrics, corticosteroids (dexamethasone or prednisone) can be considered only after other options have failed 1, 4
• Avoid traditional "migraine cocktail" components like NSAIDs (in third trimester), triptans (without specialist consultation), and opioids 1