What are the recommended treatments for headache and nausea in the first trimester of pregnancy?

Treatment of Headache and Nausea in First Trimester Pregnancy

For first trimester headache, start with acetaminophen 1000 mg as first-line treatment, and for nausea and vomiting, begin early treatment with vitamin B6 and doxylamine to prevent progression to hyperemesis gravidarum, escalating to metoclopramide if needed.

Nausea and Vomiting Management

Initial Approach

• Early treatment is critical to prevent progression to hyperemesis gravidarum, which becomes more difficult to control once established 1
• Begin with lifestyle and dietary modifications: staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, and identifying/avoiding triggers 2
• The severity of symptoms should guide treatment intensity, as the woman's perception plays a critical role in management decisions 3, 4

Stepwise Pharmacologic Treatment

First-line therapy:

• Vitamin B6 and doxylamine combination is the initial pharmacologic treatment for nausea and vomiting of pregnancy 1

Second-line therapy (moderate cases):

• Metoclopramide 10 mg (oral or IV) is safe and effective, particularly in the second and third trimesters, though it can be used earlier when needed 2, 5
• Consider nonoral routes if severe vomiting prevents oral medication absorption 2

Third-line therapy (severe cases):

• Ondansetron, promethazine, or prochlorperazine may be required for moderate to severe nausea 1
• Prochlorperazine 25 mg (oral or suppository) can relieve both nausea and headache pain directly 2
• Intravenous glucocorticoids (dexamethasone or prednisone) may be considered in severe, refractory cases after other options have failed, in consultation with obstetrics 2, 5

Important Contraindications

• Avoid metoclopramide in patients with pheochromocytoma, seizure disorder, GI bleeding, or GI obstruction 6

Headache Management

First-Line Treatment

• Acetaminophen (paracetamol) 1000 mg is the safest and preferred first-line medication for headache in pregnancy, ideally given as a suppository for better absorption 2, 7, 5
• This is particularly important in the first trimester when fetal risk from medications is highest 8

Second-Line Options

• NSAIDs (ibuprofen, naproxen) can be used episodically only during the second trimester if acetaminophen is insufficient 2, 7
• Aspirin risks are considered small when taken episodically, but must be avoided during the first and third trimesters 7
• All NSAIDs must be avoided in the third trimester due to risks of premature closure of the ductus arteriosus and other complications 7, 5

Medications for Migraine-Specific Treatment

• Metoclopramide serves dual purposes: treating both migraine-associated nausea and providing some headache relief 2, 5
• Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail, though it should be avoided in the first trimester when possible 2
• For severe refractory migraine, chlorpromazine, dimenhydrinate, or diphenhydramine can be considered 5

Strictly Contraindicated Medications

• Ergotamine derivatives and dihydroergotamine are absolutely contraindicated throughout pregnancy due to oxytocic properties that can cause fetal harm 2, 7, 8
• Opioids and butalbital-containing medications should be avoided due to risks of dependency, rebound headaches, and potential fetal harm 2
• Topiramate, candesartan, and sodium valproate are contraindicated due to teratogenic effects 2
• CGRP antagonists (gepants) have insufficient safety data and should be avoided 2

Medication Overuse Prevention

• 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 2, 9
• This is particularly important in pregnancy when treatment options are already limited 2

Red Flags Requiring Urgent Evaluation

• New-onset headache with hypertension should be considered preeclampsia until proven otherwise and requires urgent evaluation 2
• De novo headache during pregnancy usually requires expert review to exclude secondary causes 8

Prophylactic Treatment Considerations

• Prophylactic medications are best avoided during pregnancy and should only be considered for frequent and disabling attacks 2
• If absolutely necessary, propranolol has the best safety data and is the first choice, while amitriptyline can be used if propranolol is contraindicated 2, 7, 5
• Prophylactic treatment should preferably be restricted to the second and third trimesters 8

Clinical Pitfalls to Avoid

• Do not undertreat nausea and vomiting in early pregnancy—early aggressive treatment prevents progression to hyperemesis gravidarum requiring hospitalization 1, 3, 4
• Do not use the traditional ED "migraine cocktail" (NSAIDs + triptans + antiemetics) in pregnant patients—use only the antiemetic component 2
• Do not prescribe NSAIDs for extended periods or in the third trimester, even if they were safe earlier in pregnancy 7, 5
• Ensure adequate hydration with IV fluids when needed, as dehydration worsens both headache and nausea 2