What is the recommended management for acute severe migraine in pregnancy?

Acute Severe Migraine Management in Pregnancy

Acetaminophen (paracetamol) 1000 mg is the first-line treatment for acute severe migraine in pregnancy, with metoclopramide 10 mg added for nausea and synergistic analgesia, administered via non-oral routes (IV/IM) if vomiting is present. 1

First-Line Treatment Algorithm

Initial Therapy

• Acetaminophen 1000 mg should be administered first, preferably via suppository or IV route if oral intake is compromised by severe nausea or vomiting 1, 2
• Metoclopramide 10 mg IV should be added immediately, as it provides both antiemetic effects and direct analgesic properties through central dopamine receptor antagonism, not just for treating nausea 1
• IV fluid bolus should be administered to address dehydration, which is particularly important as maternal dehydration poses risks to both mother and fetus 1

Second-Line Options by Trimester

• Second trimester only: NSAIDs such as ibuprofen can be used if acetaminophen fails, but must be avoided in first and third trimesters due to specific fetal risks 1, 2
• All trimesters: Prochlorperazine 10 mg IV can substitute for metoclopramide with comparable efficacy 1

Severe Refractory Cases

When First-Line Fails

• Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail, with the most safety data available for this specific triptan 1, 2
• Corticosteroids (dexamethasone or prednisone) can be considered in consultation with obstetrics, but only after all other options have been exhausted 1

Critical Medications to AVOID

• Opioids and butalbital are absolutely contraindicated due to dependency risks, rebound headaches, and potential fetal harm 1
• Ergotamine derivatives and dihydroergotamine are contraindicated throughout pregnancy 1
• CGRP antagonists (gepants) have insufficient safety data and should be avoided 1
• NSAIDs in third trimester must be avoided due to premature ductus arteriosus closure risk 1, 2

Environment and Supportive Care

Non-Pharmacological Interventions

• Provide a quiet, dark environment in the acute care setting 1
• Ensure adequate IV hydration, as dehydration exacerbates migraine and poses maternal-fetal risks 1
• Address modifiable triggers including irregular sleep, missed meals, and dehydration 1

Red Flags Requiring Urgent Evaluation

Exclude Secondary Causes

• New headache with hypertension must be considered preeclampsia until proven otherwise and requires immediate obstetric consultation 1
• New onset headache in pregnancy with hypertension, especially if accompanied by visual changes, altered mental status, or seizures, demands urgent evaluation for preeclampsia/eclampsia 1

Discharge Planning

Home Rescue Medications

• Prescribe acetaminophen 1000 mg for home use as rescue medication 1
• Never prescribe opioids or butalbital for home use despite patient requests 1
• Counsel on lifestyle modifications: adequate hydration, regular meals, consistent sleep patterns, and trigger avoidance 1

Important Clinical Pitfalls

Medication Overuse Prevention

• Limit acute medication use to no more than 2 days per week to prevent medication overuse headache 1
• If headaches occur more than twice weekly, preventive therapy (propranolol as first choice) should be initiated rather than increasing acute medication frequency 1

Treatment Timing

• Administer medications as early as possible during the attack for maximum efficacy 1
• Non-oral routes (IV, IM, suppository) are preferred when significant nausea or vomiting is present 1

Monitoring Requirements

• Monitor for akathisia and dystonic reactions when using metoclopramide or prochlorperazine; co-administer diphenhydramine 25-50 mg to prevent extrapyramidal symptoms 1
• Regular monitoring is essential when any medications are used during pregnancy 1