What are the safe and effective treatment options for migraines during pregnancy?

Migraine Management During Pregnancy

Acetaminophen (paracetamol) 1000 mg is the first-line acute treatment for migraine during pregnancy, with NSAIDs like ibuprofen reserved for second-trimester use only, and sumatriptan considered sparingly under specialist supervision when other options fail. 1, 2

Acute Treatment Algorithm

First-Line: Acetaminophen

• Start with acetaminophen 1000 mg for all acute migraine attacks during pregnancy 1, 2
• This medication has the most extensive safety data across all trimesters 1
• Can be combined with caffeine for additional benefit 1
• Limit use to <15 days per month to prevent medication overuse headache 1, 2

Second-Line: NSAIDs (Trimester-Specific)

• Ibuprofen can be used ONLY during the second trimester when acetaminophen fails 1, 2
• Absolutely avoid NSAIDs in the first and third trimesters due to specific fetal risks 2
• Limit to <15 days per month if used 1

Third-Line: Triptans (Use Sparingly)

• 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 all triptans 1, 2
• A Swedish registry study found no increased risk for congenital malformations (OR 0.95% CI 0.80-1.12) 1
• Use the lowest effective dose and limit to <10 days per month 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, 2
• Prochlorperazine 25 mg (oral or suppository) can relieve both nausea and headache pain directly 1
• Consider nonoral routes if severe vomiting prevents oral medication absorption 1

Medications to Absolutely Avoid

Critical contraindications that must be avoided:

• Ergotamine derivatives and dihydroergotamine are contraindicated throughout pregnancy due to oxytocic properties that can harm the fetus 1, 2
• Topiramate, candesartan, and sodium valproate are contraindicated due to adverse fetal effects 1, 2
• CGRP antagonists (gepants) have insufficient safety data and should be avoided 1, 2
• Opioids and butalbital-containing medications should not be used due to risks of dependency, rebound headaches, and potential fetal harm 1, 2

Preventive Treatment (Use Only When Absolutely Necessary)

Indications for Prevention

Consider preventive therapy only when: 1, 2

• ≥2 attacks per month producing disability lasting ≥3 days per month
• Contraindication or failure of acute treatments
• Use of abortive medication >2 times per week

First-Line Preventive: Propranolol

• Propranolol 80-160 mg daily has the best available safety data for preventive therapy 1, 2
• Ideally avoid in the first trimester when possible, as first-trimester exposure may be associated with intrauterine growth restriction (IUGR), particularly with prolonged use 2
• Use the lowest effective dose and titrate according to clinical response 2
• Screen for contraindications: asthma, cardiac failure, Raynaud disease, AV block, or depression 2

Second-Line Preventive: Amitriptyline

• Amitriptyline can be used only if propranolol is contraindicated 1, 2
• Use the lowest effective dose with close monitoring 2
• May be superior for mixed migraine and tension-type headache patterns 2

Critical Pitfall

• Atenolol should be completely avoided due to more pronounced IUGR risk than propranolol 2

Non-Pharmacological Approaches (Always First-Line)

Before initiating any medication, implement these lifestyle modifications: 1, 2

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

Emergency Department Management

For severe, refractory migraine in the ED: 1

• Provide a quiet, dark environment
• Ensure adequate hydration with IV fluids
• Use metoclopramide or prochlorperazine (the antiemetic component of traditional "migraine cocktails")
• Avoid the traditional "migraine cocktail" containing NSAIDs, triptans, and opioids due to fetal risks 1
• In severe, refractory cases after other options have failed, corticosteroids (dexamethasone or prednisone) can be considered in consultation with obstetrics 1

Red Flags Requiring Urgent Evaluation

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

Additional warning signs: 1

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

Postpartum and Breastfeeding Period

Acute Treatment

• Acetaminophen 1000 mg remains the preferred first-line treatment 2, 3
• Ibuprofen is safe during breastfeeding and should be used when acetaminophen is insufficient 2, 3
• Sumatriptan is safe during breastfeeding for moderate to severe migraines unresponsive to acetaminophen or NSAIDs 2, 3

Preventive Treatment

• Propranolol 80-160 mg daily has the best safety profile for lactating women 2, 3
• Start with 80 mg daily and titrate up to 160 mg as needed 3

Common Pitfalls to Avoid

1. Medication overuse headache: Occurs with ≥15 days/month of NSAID/acetaminophen use or ≥10 days/month of triptan use 1, 2
2. Using NSAIDs in first or third trimester: Specific risks and contraindications exist 2
3. Prescribing opioids or butalbital: Creates dependency, rebound headaches, and potential fetal harm 1, 2
4. Abrupt discontinuation of propranolol: Avoid if preventive therapy needs to be stopped 2
5. Failing to screen for preeclampsia: New headache with hypertension requires urgent evaluation 1, 2

Multidisciplinary Communication

Ongoing communication among obstetricians, neurologists, and other relevant clinicians throughout pregnancy, delivery, and the postpartum period is essential to optimize maternal and fetal outcomes 2