What medications are contraindicated in the pharmacological management of a pregnant patient with a migraine?

Contraindicated Medications for Migraine in Pregnancy

Ergotamine derivatives and dihydroergotamine are absolutely contraindicated throughout pregnancy due to their oxytocic properties that can cause fetal harm, and opioids and butalbital-containing compounds should be avoided due to risks of dependency, rebound headaches, and potential fetal harm. 1, 2

Absolutely Contraindicated Medications

Ergot Alkaloids

• Ergotamine and dihydroergotamine are contraindicated in all trimesters because they possess oxytocic properties that can induce uterine contractions and cause direct harm to the fetus 1, 2, 3
• The FDA drug label explicitly states that ergotamine may cause fetal harm when administered to pregnant women and is contraindicated in women who are or may become pregnant 2
• Methysergide, another ergot derivative, should similarly be avoided throughout pregnancy 4

Preventive Medications with Teratogenic Risk

• Topiramate is contraindicated due to documented adverse effects on the fetus 1, 5
• Sodium valproate is contraindicated due to significant teratogenic risk 1, 5
• Candesartan is contraindicated due to fetal harm 1, 5

Medications with Insufficient Safety Data

• CGRP antagonists (gepants) should be avoided due to lack of adequate safety data in pregnancy 1, 5

Medications to Strongly Avoid (Not Absolute Contraindications but High Risk)

Opioids and Butalbital

• Opioids and butalbital-containing medications should not be used due to risks of maternal dependency, medication-overuse headache, and potential fetal harm 1, 5
• Despite being commonly prescribed, these agents carry significant risks and should be reserved only for exceptional circumstances when all other options have failed 1
• In a retrospective study of pregnant women treated for acute migraine, 30% received opioids and 35% received butalbital, indicating these are unfortunately still being used despite recommendations against them 6

NSAIDs in First and Third Trimesters

• NSAIDs such as ibuprofen must be avoided in the first and third trimesters due to trimester-specific risks 1, 5
• NSAIDs may only be considered during the second trimester as a second-line option when acetaminophen fails 1, 5
• The restriction in the third trimester is particularly important due to risks of premature closure of the ductus arteriosus and other cardiovascular complications 3

Triptans: Use with Extreme Caution

• Triptans are not absolutely contraindicated but should only be used sporadically under strict specialist supervision when other treatments have failed 1, 5
• Among the triptans, sumatriptan has the most safety data available, making it the preferred agent in this class if a triptan must be used 1, 5
• Some older guidelines listed triptans as contraindicated, but more recent evidence suggests they may not be associated with fetal/child adverse effects when used judiciously 3, 7

Important Clinical Caveats

Medication Overuse Risk

• Limit acute treatment to less than 10 days per month for triptans and less than 15 days per month for acetaminophen/NSAIDs to prevent medication overuse headache, which is particularly problematic in pregnancy when treatment options are already limited 1

First-Line Safe Options

• Acetaminophen (paracetamol) 1000 mg is the first-line medication for acute migraine treatment in pregnancy across all trimesters 1, 5, 3
• Metoclopramide is safe and effective for migraine-associated nausea, particularly in the second and third trimesters 1, 5

Red Flag Warning

• Any new headache in a pregnant woman with hypertension should be considered preeclampsia until proven otherwise and requires urgent evaluation rather than routine migraine treatment 1, 5