What are the recommended treatments for migraines in a pregnant woman?

Treatment for Migraines During Pregnancy

Paracetamol (acetaminophen) 1000 mg is the first-line acute treatment for migraine during pregnancy, and should be used before considering any other medication. 1

Acute Treatment Algorithm

First-Line Treatment

• Paracetamol 1000 mg (preferably as suppository for better absorption if nausea present) is the safest option throughout all trimesters 1, 2
• Can be combined with caffeine for additional benefit 1
• Limit use to <15 days per month to prevent medication overuse headache 1

Second-Line Treatment (Trimester-Specific)

• NSAIDs (ibuprofen, naproxen) can be used ONLY during the second trimester 1, 2
  • Avoid in first trimester (risk of miscarriage) and third trimester (risk of premature closure of ductus arteriosus, oligohydramnios, bleeding complications) 2
  • Limit to <15 days per month 1

Third-Line Treatment (Severe, Refractory Cases)

• Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail 1, 2
  • Has the most safety data among triptans 1
  • Limit to <10 days per month 1
  • Other triptans have insufficient pregnancy 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 second and third trimesters 1
• Prochlorperazine 25 mg (oral or suppository) can relieve both nausea and headache pain directly 1

Severe Refractory Cases (Hospital Setting)

• Corticosteroids (dexamethasone or prednisone) can be considered in consultation with obstetrics, but only after all other options have failed 1
• Provide quiet, dark environment and IV hydration 1

Preventive Treatment

Preventive medications should be avoided during pregnancy whenever possible and only considered for frequent, disabling attacks (≥2 attacks per month causing disability for ≥3 days). 1

When Prevention is Indicated:

• Two or more attacks per month producing disability for 3+ days 1
• Contraindication or failure of acute treatments 1
• Use of abortive medication more than twice per week 1

Preventive Medication Hierarchy:

• Propranolol (low dose) is the first choice with the best safety data 1, 2
• Amitriptyline (low dose) can be used if propranolol is contraindicated 1, 2

Absolutely Contraindicated Medications

The following must NEVER be used during pregnancy:

• Ergotamine derivatives and dihydroergotamine (oxytocic properties can harm fetus) 1
• Topiramate (high rate of fetal anomalies including cleft palate) 3, 1
• Sodium valproate (absolutely contraindicated in women of childbearing potential) 3, 1
• Candesartan (fetal harm) 3, 1
• CGRP antagonists (gepants) (insufficient safety data) 1
• Opioids and butalbital-containing medications (risk of dependency, rebound headaches, and potential fetal harm) 1

Non-Pharmacological Approaches (Always First-Line)

Before any medication, implement lifestyle modifications:

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

Critical Red Flags Requiring Urgent Evaluation

New headache in a pregnant woman with hypertension should be considered preeclampsia until proven otherwise and requires immediate evaluation 1

Additional warning signs:

• Sudden onset or different pattern from usual migraine 1
• Seizures associated with headache 1

Postpartum and Breastfeeding

• Paracetamol remains the preferred acute medication 1
• Ibuprofen and sumatriptan are considered safe during breastfeeding 1
• Propranolol is recommended if preventive medication is required postpartum 1

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 opioids or butalbital for rescue medication at home 1
• Do not use NSAIDs in first or third trimester even if they worked well pre-pregnancy 1, 2
• Do not assume all triptans are equally safe—sumatriptan has the most data 1