What is the recommended treatment for migraines in a pregnant patient?

Migraine Treatment in Pregnancy

Acetaminophen (paracetamol) 1000 mg is the first-line acute treatment for migraine during pregnancy, with metoclopramide added for nausea if needed. 1, 2

Acute Treatment Algorithm

First-Line: Acetaminophen

• Use acetaminophen 1000 mg as the primary acute treatment throughout all trimesters of pregnancy due to its established safety profile and minimal fetal risk 1, 2
• Limit use to <15 days per month to prevent medication overuse headache 1, 2
• Can be combined with caffeine for additional benefit 1

Second-Line: NSAIDs (Trimester-Specific)

• Ibuprofen can be used ONLY during the second trimester as a second-line option when acetaminophen fails 1, 2
• Absolutely avoid NSAIDs in the first trimester (teratogenic risk) and third trimester (premature ductus arteriosus closure, oligohydramnios) 2, 3

Third-Line: Triptans (Specialist Supervision Required)

• Sumatriptan may be used sporadically under strict specialist supervision when acetaminophen and appropriate-trimester NSAIDs have failed 1, 2
• Sumatriptan has the most safety data among triptans, though use should remain infrequent 2, 3
• Limit to <10 days per month to prevent medication overuse headache 1

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
• Prochlorperazine 25 mg (oral or suppository) can relieve both nausea and headache pain directly 1

Medications to Absolutely Avoid

Never prescribe these agents during pregnancy:

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

Preventive Treatment (Use Only When Absolutely Necessary)

Preventive medications should be avoided during pregnancy unless the patient has frequent, disabling attacks (≥2 attacks per month producing disability for ≥3 days per month). 1, 2

When Prevention is Required:

• Propranolol 80-160 mg daily is the first-choice preventive medication due to the best available safety data, though ideally avoided in the first trimester 1, 2
• Use the lowest effective dose and monitor for intrauterine growth retardation (IUGR), particularly with first-trimester exposure 2
• Amitriptyline can be used if propranolol is contraindicated 1, 2
• Never use topiramate, candesartan, or sodium valproate for prevention 1, 2

Non-Pharmacological Approaches (Always Implement First)

Before any medication, implement these lifestyle modifications:

• Maintain adequate hydration with regular fluid intake 1, 2
• Ensure regular meals to avoid hypoglycemia triggers 1, 2
• Secure consistent, sufficient sleep patterns (7-9 hours nightly) 1, 2
• Engage in appropriate physical activity (walking, prenatal yoga) 1, 2
• Identify and avoid specific migraine triggers (keep a headache diary) 1, 2
• Consider biofeedback, relaxation techniques, massage, and ice packs 1

Emergency Department Management

For pregnant patients presenting to the ED with severe migraine:

• Provide a quiet, dark environment and ensure adequate hydration with IV fluids 1
• Use metoclopramide or prochlorperazine from the traditional "migraine cocktail" - avoid NSAIDs, triptans, and opioids due to fetal risks 1
• Consider nonoral routes if severe vomiting prevents oral medication absorption 1
• In severe, refractory cases, corticosteroids (dexamethasone or prednisone) can be considered in consultation with obstetrics, but only after other options have failed 1, 4

Critical Red Flags Requiring Urgent Evaluation

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

Additional red flags include:

• Sudden onset or different pattern from usual headaches 1
• Seizures associated with headache 1
• New onset headache, especially with hypertension 1

Postpartum and Breastfeeding

• Acetaminophen 1000 mg remains the preferred acute medication during breastfeeding 2, 5
• Ibuprofen and sumatriptan are considered safe during breastfeeding 1, 2, 5
• If preventive medication is required postpartum, propranolol 80-160 mg daily is recommended as it has minimal transfer into breast milk 1, 2, 5

Common Pitfalls to Avoid

• Do not prescribe atenolol - it causes more pronounced IUGR than propranolol 2
• Do not use high-dose aspirin during breastfeeding (association with Reye's syndrome) 5
• Do not withhold treatment entirely - untreated severe migraine with associated nausea, vomiting, and dehydration may pose greater maternal and fetal risks than appropriate medication use 6, 7
• Replace any existing butalbital-containing prescriptions with acetaminophen 1000 mg to avoid dependency and withdrawal risks 1