What medications are safe to use for headaches during pregnancy?

Safe Medications for Headache During Pregnancy

Acetaminophen (paracetamol) 1000 mg is the first-line medication for treating headaches during pregnancy and should be your default choice. 1, 2

First-Line Treatment: Acetaminophen

• Acetaminophen 1000 mg is recommended as the safest and most appropriate first-line treatment for headaches throughout all trimesters of pregnancy. 1, 2, 3
• The optimal dose is 1000 mg, which can be given orally or as a suppository for better absorption if nausea is present. 3, 4
• Limit use to fewer than 15 days per month to prevent medication-overuse headache, which becomes particularly problematic during pregnancy when treatment options are restricted. 2, 5
• The FDA label states that pregnant women should consult a health professional before use, though extensive clinical experience supports its safety profile. 6

Second-Line Treatment: NSAIDs (Second Trimester Only)

• NSAIDs such as ibuprofen can be used during the second trimester only when acetaminophen fails to provide adequate relief. 1, 2
• Strictly avoid NSAIDs during the first and third trimesters due to specific fetal risks including cardiac complications and premature closure of the ductus arteriosus in the third trimester. 1, 2
• When used in the second trimester, limit to episodic use (fewer than 15 days per month) and use the lowest effective dose. 2, 3

Third-Line Treatment: Triptans (Specialist Supervision Required)

• Sumatriptan may be considered for severe, refractory headaches under strict specialist supervision when first-line options fail. 1, 2
• Sumatriptan has the most safety data among triptans, though it should only be used sporadically and not as routine therapy. 1, 7
• Recent evidence suggests triptans may not be associated with fetal/child adverse effects, but they remain a specialist-supervised option rather than first-line therapy. 7

Adjunctive Therapy for Nausea

• Metoclopramide 10 mg (oral or IV) is safe and effective for migraine-associated nausea, particularly during the second and third trimesters. 1, 2
• Prochlorperazine 25 mg (oral or suppository) can relieve both nausea and headache pain directly and is unlikely to be harmful during pregnancy. 2, 3

Medications to Absolutely Avoid

• Ergotamine derivatives and dihydroergotamine are contraindicated throughout pregnancy due to oxytocic properties that can cause uterine contractions and harm the fetus. 1, 2
• Opioids and butalbital-containing medications should not be used due to risks of dependency, medication-overuse headache, and potential fetal harm. 1, 2
• CGRP antagonists (gepants) have insufficient safety data in pregnancy and must be avoided. 2
• Topiramate, candesartan, and sodium valproate are contraindicated due to known teratogenic effects. 1, 2

Non-Pharmacological Approaches (Try First)

• Before initiating any medication, attempt non-pharmacological interventions: staying well hydrated, maintaining regular meals to avoid hypoglycemia triggers, securing sufficient and consistent sleep patterns, and identifying/avoiding specific migraine triggers. 1, 2
• Additional effective strategies include biofeedback, relaxation techniques, massage, and ice packs applied to the head or neck. 2, 3

Critical Red Flags Requiring Urgent Evaluation

• A new headache in a pregnant woman with hypertension should be considered preeclampsia until proven otherwise and requires immediate evaluation. 2
• Any headache that is progressive and refractory to treatment, acute in onset and severe, postural, or different from typical headaches warrants cerebral and cerebrovascular imaging. 8

Preventive Treatment (Rarely Indicated)

• Preventive medications should be avoided during pregnancy unless absolutely necessary for frequent and disabling attacks (≥2 attacks per month producing disability lasting ≥3 days per month). 1, 2
• If prevention is required, propranolol has the best safety profile and is the first choice, though it should preferably only be used during the second and third trimesters. 1, 2, 3
• Amitriptyline can be considered if propranolol is contraindicated, but has less favorable safety data. 1, 2

Common Pitfalls to Avoid

• Do not prescribe combination analgesics containing butalbital or opioids for home use—these carry significant risks of dependency and rebound headaches. 2
• Do not use the traditional emergency department "migraine cocktail" (NSAIDs + triptans + antiemetics) in pregnant patients—modify to use only the antiemetic component. 2
• Do not assume all triptans have equal safety data—sumatriptan specifically has the most evidence supporting its use when needed. 1, 7