What are the recommended treatments for managing migraine in pregnancy?

Managing Migraine in Pregnancy

Paracetamol (acetaminophen) 1000 mg is the first-line acute treatment for migraine during pregnancy, with NSAIDs like ibuprofen reserved for second-trimester use only, and preventive therapy with propranolol considered only for frequent, disabling attacks. 1, 2

Acute Treatment Algorithm

First-Line: Paracetamol

• Use paracetamol 1000 mg as the initial treatment throughout all trimesters of pregnancy 1, 2
• Limit use to <15 days per month to prevent medication overuse headache 1
• Can be given orally or as a suppository if vomiting prevents oral absorption 1

Second-Line: NSAIDs (Trimester-Specific)

• Ibuprofen can be used ONLY during the second trimester 1, 2
• Avoid NSAIDs completely in the first and third trimesters due to specific fetal risks 2
• Limit to <15 days per month if used 1

Third-Line: Triptans (Specialist Supervision Required)

• Sumatriptan may be used sporadically under strict specialist supervision when paracetamol and NSAIDs fail 1, 2
• Sumatriptan has the most safety data among all triptans 1, 2
• Limit to <10 days per month to prevent medication overuse headache 1
• Other triptans have insufficient safety data and should be avoided 1

Antiemetic Therapy for Nausea

• Metoclopramide 10 mg (oral or IV) is safe and effective for migraine-associated nausea, particularly in the second and third trimesters 1, 2
• Prochlorperazine 25 mg (oral or suppository) can relieve both nausea and headache pain directly 1

Medications That Are Absolutely Contraindicated

Never Use During Pregnancy:

• Ergotamine derivatives and dihydroergotamine are contraindicated throughout pregnancy due to oxytocic properties that can harm the fetus 1, 2
• Topiramate, candesartan, and sodium valproate are contraindicated due to adverse fetal effects 1, 2
• CGRP antagonists (gepants) have insufficient safety data and should be avoided 1, 2
• Opioids and butalbital-containing medications should not be used due to risks of dependency, rebound headaches, and potential fetal harm 1, 2

Preventive Treatment (Only for Severe, Frequent Cases)

When to Consider Prevention:

• Only consider preventive therapy for ≥2 attacks per month producing disability lasting ≥3 days per month, or when acute treatments have failed or are contraindicated 2
• Preventive medications are best avoided during pregnancy due to potential fetal harm 1, 2

First-Line Preventive: Propranolol

• Propranolol 80-160 mg daily in long-acting formulations has the best safety data and is the first choice for preventive therapy 1, 2
• Screen for contraindications: asthma, cardiac failure, Raynaud disease, atrioventricular block, or depression 2

Second-Line Preventive: Amitriptyline

• Amitriptyline can be used if propranolol is contraindicated 1, 2
• Use low doses and only when absolutely necessary 1

Non-Pharmacological Approaches (Always First-Line)

Lifestyle Modifications:

• Maintain adequate hydration with regular fluid intake 1, 2
• Ensure regular meals to avoid hypoglycemia triggers 1, 2
• Secure consistent, sufficient sleep patterns 1, 2
• Engage in appropriate physical activity 1, 2
• Identify and avoid specific migraine triggers 1, 2

Additional Non-Pharmacological Options:

• Consider biofeedback, relaxation techniques, massage, and ice packs 1
• Provide a quiet, dark environment during acute attacks 1

Critical Red Flags

Preeclampsia Warning:

• A new headache in a pregnant woman with hypertension should be considered part of preeclampsia until proven otherwise and requires urgent evaluation 1, 2
• New onset headache in pregnancy, especially with hypertension, demands immediate assessment 1

Emergency Department Management

Modified "Migraine Cocktail" for Pregnancy:

• Use only the antiemetic component (metoclopramide or prochlorperazine) from the traditional ED migraine cocktail 1
• Avoid NSAIDs, triptans, and opioids in the ED setting due to fetal risks 1
• Provide IV fluids for adequate hydration 1

Refractory Cases:

• In severe, refractory migraine, corticosteroids like dexamethasone or prednisone can be considered in consultation with obstetrics, but only after other options have failed 1

Postpartum and Breastfeeding Period

Acute Treatment While Breastfeeding:

• Paracetamol 1000 mg remains the preferred acute medication during breastfeeding 2, 3
• Ibuprofen and sumatriptan are considered safe during breastfeeding 2, 3
• The FDA recommends avoiding breastfeeding for 12 hours after sumatriptan treatment to minimize infant exposure 3

Preventive Treatment While Breastfeeding:

• Propranolol 80-160 mg daily is recommended as the first-line preventive medication postpartum due to minimal transfer into breast milk 2, 3

Important Clinical Caveats

Medication Overuse Headache Prevention:

• Medication overuse headache can occur with ≥15 days/month use of NSAIDs or paracetamol, and ≥10 days/month use of triptans 1, 2
• This is particularly important in pregnancy when treatment options are already limited 1

Monitoring Requirements:

• Regular monitoring is essential when any medications are used during pregnancy, especially for preventive treatments 1, 2
• Multidisciplinary communication among experienced clinicians should occur throughout pregnancy, peridelivery, and postpartum 2