What are the recommended treatments for migraine prophylaxis in a pregnant patient?

Migraine Prophylaxis in Pregnancy

Propranolol is the first-line preventive medication for migraine during pregnancy when prophylaxis becomes necessary, with amitriptyline as the alternative if propranolol is contraindicated. 1, 2, 3

When to Consider Prophylaxis

Preventive treatment should only be initiated in pregnant women with:

• Two or more disabling migraine attacks per month producing disability for 3 or more days 1
• Contraindication to or failure of acute treatments 1
• Use of abortive medication more than twice weekly 1
• Presence of uncommon migrainous conditions 1

The threshold for starting prophylaxis should be high during pregnancy, as most preventive medications carry potential fetal risks. 1, 3

First-Line Prophylactic Agent

Propranolol has the best available safety data among preventive options and should be used first. 1, 4, 2, 3

• Dosing: 80-160 mg daily in long-acting formulations 5
• Beta-blockers (metoprolol and propranolol) are the only agents with acceptable safety profiles for prophylaxis during pregnancy 2
• Propranolol can be used throughout pregnancy when benefits outweigh risks 4

Second-Line Prophylactic Agent

Amitriptyline is the alternative if propranolol is contraindicated or not tolerated. 1, 6

• Use low doses when necessary 6, 7
• Tricyclic antidepressants have been used during pregnancy with reasonable safety data 6

Medications That Are Absolutely Contraindicated

Three medications must never be used for migraine prophylaxis in pregnancy:

• Topiramate - associated with higher rates of fetal anomalies including cleft lip/palate 1, 3
• Sodium valproate - causes major congenital malformations and neurodevelopmental delays 1, 3
• Candesartan - contraindicated due to adverse fetal effects 1

Medications to Avoid Due to Insufficient Safety Data

CGRP antagonists (gepants) and CGRP monoclonal antibodies lack safety data in pregnancy and should be avoided. 1

• The 2025 American College of Physicians guideline specifically notes these agents are not appropriate for pregnant patients 8
• No human pregnancy data exists to support their use 1

Non-Pharmacological Approaches

Before initiating any prophylactic medication, implement lifestyle modifications:

• Maintain adequate hydration with regular fluid intake 1, 3
• Ensure regular meals to avoid hypoglycemia as a trigger 1, 3
• Secure consistent, sufficient sleep patterns 1, 3
• Identify and avoid specific migraine triggers 1, 3
• Consider biofeedback, relaxation techniques, massage, and ice packs 4, 3

These non-pharmacological approaches should always be the foundation of migraine management during pregnancy and may reduce or eliminate the need for prophylactic medications. 3, 7

Critical Clinical Pitfalls

Do not use the same prophylactic algorithm recommended for non-pregnant adults. The 2025 American College of Physicians guideline explicitly states its recommendations apply only to "nonpregnant or nonlactating adults" and lists pregnancy as an exclusion criterion. 8

Monitor closely if prophylaxis is initiated. Regular monitoring is essential when preventive medications are used during pregnancy, particularly given the limited treatment options. 1

Reassess the need for prophylaxis throughout pregnancy. Many women (60-70%) experience improvement in migraine frequency during the second and third trimesters, which may allow discontinuation of prophylactic therapy. 4, 7