What are the recommended medications for migraine headaches during pregnancy?

Migraine Medications During Pregnancy

Acetaminophen (paracetamol) 1000 mg is the first-line medication for acute migraine treatment throughout all trimesters of pregnancy, with metoclopramide 10 mg added for nausea if needed. 1, 2

Acute Treatment Algorithm

First-Line Treatment

• Acetaminophen 1000 mg is the safest and preferred acute treatment option throughout pregnancy, ideally given as a suppository for better absorption 1, 2, 3
• Limit use to <15 days per month to prevent medication-overuse headache 1, 2

Second-Line Treatment (Trimester-Specific)

• NSAIDs (ibuprofen, naproxen) can only be used during the second trimester as a second-line option when acetaminophen fails 1, 2, 4
• Avoid NSAIDs completely in the first and third trimesters due to risks of miscarriage (first trimester) and premature closure of the ductus arteriosus plus bleeding complications (third trimester) 2, 4

Third-Line Treatment (Specialist Supervision Required)

• Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail, as it has the most safety data among triptans 1, 2, 4
• Limit to <10 days per month to prevent medication-overuse headache 1, 2
• Other triptans have insufficient pregnancy safety data and should be avoided 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 1, 2, 3
• Prochlorperazine 25 mg (oral or suppository) can relieve both nausea and headache pain directly 1
• Consider non-oral routes if severe vomiting prevents oral medication absorption 1

Medications That Are Absolutely Contraindicated

Never Use During Pregnancy

• Ergotamine derivatives and dihydroergotamine are contraindicated throughout pregnancy due to oxytocic properties that can cause uterine contractions and harm the fetus 1, 2, 3
• Topiramate, candesartan, and sodium valproate are contraindicated due to teratogenic 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 (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 80-160 mg daily has the best safety profile and is the first choice for preventive therapy 1, 2, 3
• Amitriptyline can be considered if propranolol is contraindicated (e.g., asthma, cardiac failure, Raynaud disease) 1, 2
• Regular monitoring is essential when preventive medications are used during pregnancy 1, 2

Non-Pharmacological Approaches (Always First-Line)

Before initiating any pharmacological treatment, implement these strategies:

• Stay well hydrated with regular fluid intake throughout the day 1, 2
• Maintain regular meals to avoid hypoglycemia triggers 1, 2
• Secure sufficient and consistent sleep patterns 1, 2
• Engage in appropriate physical activity 1, 2
• Identify and avoid specific migraine triggers 1, 2
• Consider biofeedback, relaxation techniques, massage, and ice packs 1, 3

Critical Red Flags

A new headache in a pregnant woman with hypertension should be considered part of preeclampsia until proven otherwise and requires urgent evaluation. 1, 2

Postpartum and Breastfeeding Period

• Acetaminophen remains the preferred acute medication during breastfeeding 1, 5, 2
• Ibuprofen and sumatriptan are considered safe during breastfeeding 1, 5, 2
• Propranolol 80-160 mg daily is recommended if preventive medication is required postpartum due to minimal transfer into breast milk 1, 5, 2

Common Pitfalls to Avoid

• Do not use the traditional ED "migraine cocktail" (NSAIDs + triptans + antiemetics) in pregnant patients—use only the antiemetic component 1
• Do not prescribe NSAIDs in the first or third trimester, even if they worked well before pregnancy 1, 2
• Do not continue preventive medications from before pregnancy without reassessing their safety profile 1, 2
• Monitor for medication-overuse headache, which is particularly problematic during pregnancy when treatment options are limited 1, 2