What is the recommended management for a headache during pregnancy?

Management of Headache in Pregnancy

Acetaminophen 1000 mg is the first-line treatment for acute headache in pregnancy, with lifestyle modifications attempted first when feasible. 1, 2

Initial Critical Assessment

Before treating any headache in pregnancy, immediately exclude life-threatening causes:

• New headache with hypertension must be considered preeclampsia until proven otherwise and requires urgent evaluation 1, 2
• Assess for focal neurological deficits, visual changes, altered consciousness, or seizures—these require immediate neuroimaging 3
• Consider cerebral venous thrombosis, dissection, and pituitary apoplexy, which occur more frequently in pregnancy 4
• Maintain high suspicion for carbon monoxide toxicity 4

Non-Pharmacological Management (First-Line Approach)

Before initiating medications, implement lifestyle modifications:

• Maintain adequate hydration with regular fluid intake 5, 1
• Ensure regular meals to avoid hypoglycemia triggers 5, 1
• Secure consistent, sufficient sleep patterns 5, 1
• Engage in appropriate physical activity 5, 1
• Identify and avoid specific migraine triggers 1
• Consider biofeedback, relaxation techniques, massage, and ice packs 1, 6

Acute Pharmacological Treatment Algorithm

First-Line: Acetaminophen

• Acetaminophen 1000 mg orally (preferably as suppository) is the safest first-line option 1, 2, 6
• FDA labeling advises asking a health professional before use if pregnant or breastfeeding 7
• Limit use to <15 days per month to prevent medication overuse headache 1, 2

Second-Line: NSAIDs (Second Trimester Only)

• Ibuprofen 400-800 mg can be used ONLY during the second trimester 1, 2
• Absolutely avoid NSAIDs in the first and third trimesters due to specific fetal risks 2
• When used episodically in second trimester, risks are considered small 6

Antiemetics for Nausea

• Metoclopramide 10 mg (oral or IV) is safe and effective, particularly in second and third trimesters 1, 2
• Prochlorperazine 25 mg (oral or suppository) can relieve both nausea and headache pain directly 1
• These are the only components of the traditional "migraine cocktail" that should be used in pregnancy 1

Third-Line: Triptans (Specialist Supervision Only)

• Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail 1, 2
• Sumatriptan has the most safety data among triptans 1, 2
• Limit to <10 days per month to prevent medication overuse headache 1, 2

Severe Refractory Cases

• Corticosteroids (dexamethasone or prednisone) can be considered in consultation with obstetrics, but only after other options have failed 1

Medications to ABSOLUTELY AVOID

The following are contraindicated and must never be used:

• Ergotamine derivatives and dihydroergotamine (contraindicated due to oxytocic properties that can harm the fetus) 1, 2
• Topiramate, candesartan, and sodium valproate (contraindicated due to adverse fetal effects) 1, 2
• CGRP antagonists (gepants) (insufficient safety data) 1, 2
• Opioids and butalbital-containing medications (risk of dependency, rebound headaches, and potential fetal harm) 5, 1, 2

Preventive Treatment (Rarely Indicated)

Preventive medications should be avoided during pregnancy unless absolutely necessary for frequent, disabling attacks:

• Propranolol 80-160 mg daily is the first choice if prevention is required (best safety data, though ideally avoided in first trimester) 1, 2
• Amitriptyline can be used if propranolol is contraindicated 1, 2
• Monitor for intrauterine growth retardation (IUGR) with propranolol, particularly with first trimester exposure 2
• Use lowest effective dose and titrate according to clinical response 2
• Avoid atenolol completely due to more pronounced IUGR risk 2

Postpartum Management

Treatment options expand after delivery:

• Acetaminophen 650-1000 mg every 4-6 hours remains first-line (maximum 4 g/day) 3
• Ibuprofen 400-800 mg every 6 hours is safe during breastfeeding (maximum 2.4 g/day) 3
• Sumatriptan is safe during breastfeeding for severe migraine 3
• Propranolol 80-160 mg daily is the preferred preventive agent during breastfeeding (minimal infant exposure through breast milk) 2, 3
• Continue avoiding opioids postpartum due to dependency and medication-overuse headache risks 3

Critical Pitfalls to Avoid

• Never discharge a pregnant patient with new headache and hypertension without excluding preeclampsia 1, 2
• Do not use the traditional ED "migraine cocktail" in pregnancy—only use the antiemetic component 1
• Avoid all medications in the first trimester when possible, as this is when congenital malformation risk is greatest 2
• Do not prescribe opioids or butalbital for home use 1
• Ensure multidisciplinary communication among experienced clinicians throughout pregnancy and postpartum 2