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

Headache Treatment in Pregnancy

Acetaminophen (paracetamol) 1000 mg is the first-line treatment for headaches during pregnancy due to its established safety profile throughout all trimesters. 1

Acute Treatment Algorithm

First-Line: Acetaminophen

• Acetaminophen 1000 mg is the preferred initial treatment for any headache in pregnancy, with the best safety data across all trimesters 1, 2, 3
• Can be administered orally or as a suppository for better absorption when nausea is present 2
• Limit use to less than 15 days per month to prevent medication-overuse headache 1

Second-Line: NSAIDs (Second Trimester Only)

• Ibuprofen can be used ONLY during the second trimester when acetaminophen fails 1, 3
• NSAIDs are contraindicated in the first and third trimesters due to risks of spontaneous abortion (first trimester) and premature closure of the ductus arteriosus (third trimester) 1, 3
• Use episodically and sparingly even during the second trimester 2

Third-Line: Triptans (Under Specialist Supervision)

• Sumatriptan may be used sporadically under strict specialist supervision when acetaminophen and NSAIDs fail 1, 3
• Sumatriptan has the most safety data among triptans, though evidence remains limited 1
• Should be reserved for severe, disabling attacks that do not respond to first-line options 3

Adjunctive Antiemetic Therapy

• Metoclopramide 10 mg is safe and effective for migraine-associated nausea, particularly in the second and third trimesters 1
• Prochlorperazine can be used for both nausea and headache pain relief 1
• Consider non-oral routes (IV, suppository) if severe vomiting prevents oral medication absorption 1

Preventive Treatment (Rarely Indicated)

Preventive medications should be avoided during pregnancy unless headaches are frequent and severely disabling. 1

When Prevention is Necessary:

• Consider only if ≥2 attacks per month producing disability for ≥3 days 1
• Propranolol is the first-choice preventive medication with the best available safety data 1
• Amitriptyline can be used if propranolol is contraindicated 1

Absolutely Contraindicated Preventive Medications:

• Topiramate, candesartan, and sodium valproate are strictly contraindicated due to teratogenic effects 1
• CGRP antagonists (gepants) and ergot alkaloids have insufficient safety data and must be avoided 1

Critical Red Flags Requiring Urgent Evaluation

Any new headache in a pregnant woman with hypertension should be considered preeclampsia until proven otherwise. 1

Additional warning signs requiring immediate evaluation include: 1

• Sudden onset or thunderclap headache
• Progressive headache refractory to treatment
• Headache with neurologic signs or symptoms
• Seizures associated with headache

Non-Pharmacological Approaches (Always First-Line)

Before initiating any medication, explore lifestyle modifications: 1

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

Medications to Absolutely Avoid

Never use the following medications during pregnancy: 1

• Opioids and butalbital-containing compounds - risk of dependency, rebound headaches, and potential fetal harm
• Ergotamine derivatives and dihydroergotamine - contraindicated throughout pregnancy due to oxytocic properties
• Topiramate, candesartan, sodium valproate - teratogenic effects
• CGRP antagonists - insufficient safety data

Postpartum and Breastfeeding Considerations

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

Common Pitfalls to Avoid

1. Do not use NSAIDs in the first or third trimester - this is a critical contraindication that many clinicians overlook 1, 3
2. Do not prescribe opioids or butalbital despite patient requests - these create more problems than they solve in pregnancy 1
3. Do not assume all headaches are benign - maintain high suspicion for preeclampsia, especially with new-onset headache and hypertension 1
4. Do not use multiple acute medications frequently - this leads to medication-overuse headache, which is particularly problematic when treatment options are already limited 1