What are the recommended treatments for migraines during the second trimester of pregnancy?

Migraine Treatment in the Second Trimester of Pregnancy

For acute migraine treatment in the second trimester, use acetaminophen 1000 mg as first-line therapy, with ibuprofen as a safe second-line option specifically during this trimester, and reserve sumatriptan for severe refractory cases under specialist supervision. 1

Acute Treatment Algorithm

First-Line: Acetaminophen

• Acetaminophen (paracetamol) 1000 mg is the safest and preferred first-line medication for acute migraine attacks during the second trimester 1, 2
• Preferably administered as a suppository for better absorption if nausea is present 3
• Limit use to less than 15 days per month to prevent medication overuse headache 1

Second-Line: NSAIDs (Second Trimester Only)

• Ibuprofen can be used safely during the second trimester specifically as a second-line option when acetaminophen fails 1, 4
• NSAIDs must be avoided in the first and third trimesters due to specific fetal risks 2
• The risks with episodic NSAID use during the second trimester are considered small 3
• Limit to less than 15 days per month to avoid medication overuse headache 1

Third-Line: Triptans (Severe Cases Only)

• Sumatriptan may be used sporadically under strict specialist supervision when acetaminophen and NSAIDs fail 1, 2
• Sumatriptan has the most safety data among triptans in pregnancy 1, 4
• Should only be considered for severe, disabling attacks that are unresponsive to other treatments 2

Adjunctive Therapy for Nausea

• Metoclopramide is safe and effective for migraine-associated nausea during the second trimester 1, 3
• Consider nonoral routes if severe vomiting prevents oral medication absorption 1
• Prochlorperazine is also unlikely to be harmful during pregnancy 3

Preventive Treatment (Rarely Indicated)

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

When Prevention is Necessary:

• Propranolol has the best safety data and is the first-choice preventive agent 1, 3
• Dose range: 80-160 mg oral once or twice daily in long-acting formulations 5
• Amitriptyline can be used if propranolol is contraindicated 1
• Metoprolol is also acceptable as a beta-blocker alternative 3, 6

Absolutely Contraindicated Preventive Agents:

• Topiramate, candesartan, and sodium valproate are contraindicated due to adverse fetal effects 5, 1
• Sodium valproate is absolutely contraindicated in women of childbearing potential 5

Medications to Strictly Avoid

Never use the following medications during pregnancy:

• Opioids and butalbital-containing medications (risk of dependency, rebound headaches, and fetal harm) 1
• Ergotamine derivatives and dihydroergotamine (contraindicated due to fetal risks) 1, 3
• CGRP antagonists (gepants) - insufficient safety data 1

Non-Pharmacological Approaches (Always First)

Before initiating any medication, implement lifestyle modifications:

• Maintain adequate hydration with regular fluid intake 1
• Ensure regular meals to avoid hypoglycemia triggers 1
• Secure consistent, sufficient sleep patterns 1
• Identify and avoid specific migraine triggers 1
• Consider biofeedback, relaxation techniques, massage, and ice packs 1, 3

Critical Safety Considerations

Medication Overuse Headache Prevention:

• Limit triptans to less than 10 days per month 1
• Limit acetaminophen and NSAIDs to less than 15 days per month 1
• This is particularly important in pregnancy when treatment options are already limited 1

Red Flags Requiring Urgent Evaluation:

• Any 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

Common Pitfall to Avoid:

The traditional emergency department "migraine cocktail" containing NSAIDs, triptans, and opioids must be modified for pregnant patients—use only the antiemetic component (metoclopramide or prochlorperazine) 1