What are the pregnancy-safe abortive medications for migraine?

Pregnancy-Safe Abortive Medications for Migraine

Acetaminophen (paracetamol) 1000 mg is the first-line abortive medication for migraine throughout all trimesters of pregnancy, with the safest evidence profile. 1, 2

First-Line Treatment

• Acetaminophen 1000 mg is recommended as the safest option for acute migraine treatment during pregnancy, preferably administered as a suppository for better absorption if nausea is present 1, 3
• This medication can be used throughout all trimesters without trimester-specific restrictions 1, 2
• Limit use to less than 15 days per month to prevent medication overuse headache 1

Second-Line Treatment Options

NSAIDs (Trimester-Specific Use)

• Ibuprofen 400-800 mg can be used as a second-line option only during the second trimester 1, 2, 4
• NSAIDs must be avoided in the first trimester due to risks of implantation issues and miscarriage, and are contraindicated after approximately 20 weeks gestation due to risks of premature ductus arteriosus closure and oligohydramnios 5, 4
• If NSAIDs are used between 20-30 weeks, limit to the lowest effective dose for the shortest duration (ideally less than 48 hours), and consider ultrasound monitoring for oligohydramnios if treatment extends beyond 48 hours 5

Triptans (Specialist Supervision Required)

• Sumatriptan may be used sporadically under strict specialist supervision when acetaminophen and appropriate-trimester NSAIDs fail 1, 2, 4
• Sumatriptan has the most safety data among triptans in pregnancy, though it should be reserved for severe, refractory cases 1, 4
• Limit use to less than 10 days per month to prevent medication overuse headache 1

Adjunctive Antiemetic Therapy

• Metoclopramide 10 mg (oral or IV) is safe and effective for migraine-associated nausea, particularly in the second and third trimesters 6, 1, 2
• Prochlorperazine 25 mg (oral or suppository) can relieve both nausea and headache pain directly 6, 2
• Consider nonoral routes if severe vomiting prevents oral medication absorption 1

Medications to Absolutely Avoid

• Ergotamine derivatives and dihydroergotamine are contraindicated throughout pregnancy due to oxytocic properties that can harm the fetus 6, 1
• Opioids and butalbital-containing medications should not be used due to risks of dependency, rebound headaches, and potential fetal harm 1
• CGRP antagonists (gepants) have insufficient safety data and should be avoided 1

Critical Clinical Pitfalls

• The traditional emergency department "migraine cocktail" (NSAIDs + triptans + antiemetics) must be modified in pregnancy—use only the antiemetic component (metoclopramide or prochlorperazine) 1
• Any new headache in a pregnant woman with hypertension should be considered preeclampsia until proven otherwise and requires urgent evaluation 1
• Always counsel patients on lifestyle modifications (hydration, regular meals, consistent sleep, trigger avoidance) as these should precede or accompany any medication use 1