How are headache and migraine managed during pregnancy?

Updated: Aug 20, 2019
  • Author: Carmel Armon, MD, MSc, MHS; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Answer

Answer

Migraine is extremely common among young women. Hence, optimization of its management during pregnancy is a concern that is relevant to most young female migraineurs. Ideally, management should be optimized before the patient considers pregnancy (see Migraine Headache), and the woman should discuss her plans to become pregnant with the practitioner treating the migraine, so that any medications contraindicated during pregnancy, particularly during early gestation, can be avoided.

Most preventive and mechanism-specific treatments are contraindicated before conception or during pregnancy, because the small but definite risk to the fetus cannot be justified in view of the therapeutic alternatives available, even if these alternatives are less effective than the contraindicated drugs.

In December 2009, the US Food and Drug Administration (FDA) posted a statement on its MedWatch Web site that highlighted the risks of valproate sodium and related products (valproic acid and divalproex sodium) and encouraged consideration of “alternate therapies, especially if using valproate to treat migraines or other conditions not usually considered to be life-threatening.”

Approximately 60-70% of migraineurs improve spontaneously during pregnancy, usually in the third or fourth month. On occasion, the first migraine attack occurs during pregnancy, usually during the first trimester. New onset of aura may occur during the second and third trimesters.

Headaches often return during the first week post partum [14] ; however, lactation may also affect the presence of headache. Postpartum headaches occur in about 34% of women, typically from days 3 to 6. Postpartum headache is usually less severe than the typical migraine and is usually bifrontal, prolonged, and associated with photophobia, nausea, and anorexia.

The onset of a new severe headache, especially in a nonmigraineur, should prompt evaluation of other diagnoses (eg, intracranial hemorrhage, temporal arteritis, internal carotid dissection, cerebral venous thrombosis [CVT], reversible posterior leukoencephalopathy [RPLE], meningitis, and pituitary apoplexy). New onset of migraine with aura can be caused by vasculitis, brain tumors, and occipital arteriovenous malformations.

Some brain tumors grow rapidly during pregnancy (eg, including meningiomas, choriocarcinomas, and pituitary tumors. Arteriovenous malformations have been found more commonly during pregnancy and tend to bleed in the middle toward the end of pregnancy; aneurysms are more likely to bleed during weeks 30-40. CVT occurs most frequently in the peripartum period.

Several retrospective studies showed that migraineurs are not at increased risk of miscarriage, toxemia, congenital malformations, and still births. [15] A subsequent prospective study found that relative to 3.1% of nonmigraineurs, 9% of migraineurs had hypertensive disorders during pregnancy. [16] There was also a trend toward a higher rate of low-birth-weight infants in the migraine group.

Pharmacologic options for treatment of headaches during pregnancy (see Table 1 below) are limited and should be avoided if possible. Acceptable agents for acute attacks include acetaminophen, caffeine, and opioids. Ibuprofen and naproxen are also acceptable before the third trimester. Caffeine is particularly effective for women who do not habitually consume caffeine and women in whom caffeine withdrawal does not trigger migraine. Antiemetics that may be considered for use during pregnancy are prochlorperazine and promethazine.

Table 1. Pregnancy and Breastfeeding Risk for Medications Used to Treat Migraine (Open Table in a new window)

Generic Name

level of Risk in Pregnancy

Breastfeeding

Acetaminophen

B

Caution

Dihydroergotamine

X

Contraindicated

Ergotamine

X

Contraindicated

5-HT1 agonists

C

Probably compatible

Aspirin

C (D in 3rd trimester)

Compatible

Caffeine

B

Compatible

Ibuprofen

B (D in 3rd trimester)

Compatible

Naproxen

B (D in 3rd trimester)

Compatible

Codeine

C (D at term or prolonged use)

Compatible

Meperidine

B (D at term or prolonged use)

Compatible

Morphine

B (D at term or prolonged use)

Compatible

Prednisolone

C (D in 3rd trimester)

Compatible

Prochlorperazine

C

Concern

5-HT1 = serotonin receptor subtype 1.


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