Safe Medications for Acute Migraine in Pregnancy
Paracetamol (acetaminophen) 1000 mg is the first-line and safest medication for treating acute migraine during pregnancy. 1, 2
First-Line Treatment
- Paracetamol 1000 mg should be used as the initial treatment for acute migraine attacks throughout all trimesters of pregnancy 1, 2
- This dose can be administered orally or as a suppository for better absorption if nausea is severe 3
- Limit use to less than 15 days per month to prevent medication overuse headache 1
- Combining paracetamol with caffeine may provide additional benefit 1
Second-Line Options (Trimester-Specific)
NSAIDs - Second Trimester Only
- Ibuprofen can be used as a second-line option only during the second trimester when paracetamol fails 1, 2
- NSAIDs must be completely avoided in the first and third trimesters due to specific fetal risks including cardiac defects early and premature closure of the ductus arteriosus late in pregnancy 2, 4
- Limit NSAID use to less than 15 days per month to prevent medication overuse headache 1
Triptans - Use Sparingly Under Supervision
- Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail 1, 2
- Sumatriptan has the most safety data among all triptans, with a Swedish registry study showing no increased risk for congenital malformations (OR 0.95% CI 0.80-1.12) 1
- Use the lowest effective dose and limit to less than 10 days per month to prevent medication overuse headache 1
- Take early in the attack when headache is still mild for best efficacy 5
Adjunctive 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
- In the emergency department setting, use only the antiemetic component of the traditional "migraine cocktail" (metoclopramide or prochlorperazine), avoiding NSAIDs, triptans, and opioids 1
Medications to Absolutely Avoid
Contraindicated Throughout Pregnancy
- Ergotamine derivatives and dihydroergotamine are contraindicated due to oxytocic properties that can harm the fetus 1, 2
- Opioids and butalbital-containing medications should not be used due to risks of dependency, rebound headaches, and potential fetal harm 1, 2
- CGRP antagonists (gepants) have insufficient safety data and should be avoided 1, 2
Non-Pharmacological Approaches (Always First)
Before initiating any medication, implement these strategies:
- Maintain adequate hydration with regular fluid intake 1, 2
- Ensure regular meals to avoid hypoglycemia triggers 1, 2
- Secure consistent, sufficient sleep patterns 1, 2
- Identify and avoid specific migraine triggers 1, 2
- Consider biofeedback, relaxation techniques, massage, and ice packs 1
- Provide a quiet, dark environment during acute attacks 1
Critical Red Flags Requiring Urgent Evaluation
- A new headache in a pregnant woman with hypertension should be considered preeclampsia until proven otherwise and requires urgent evaluation 1, 2
- New onset headache in pregnancy, especially with hypertension, warrants immediate assessment 1
- Sudden onset or different pattern headache requires urgent evaluation 1
- Seizures associated with headache demand immediate attention 1
Common Pitfalls to Avoid
- Never prescribe NSAIDs in the first or third trimester despite their effectiveness—the fetal risks outweigh benefits 2, 4
- Avoid the traditional ED "migraine cocktail" in pregnant patients; use only the antiemetic component 1
- Do not use opioids or butalbital even for severe refractory cases—these create dependency and medication overuse headache 1, 2
- Monitor for medication overuse headache which can develop with frequent acute medication use, further complicating management 1, 2