Migraine Treatment in Pregnant Women Presenting to Acute Care

A Retrospective Observational Study

Katherine T. Hamilton, MD; Matthew S. Robbins, MD


Headache. 2019;59(2):173-179. 

In This Article

Abstract and Introduction


Objective To assess the acute treatment of pregnant women presenting to a hospital with migraine.

Background Migraine is a common problem in pregnancy; however, migraine treatment is challenging in pregnant women for fears of medication teratogenicity and lack of data in this population. To date, no study has directly explored physician practices for treatment of acute migraine in pregnant women.

Methods We conducted a retrospective chart review of medication administration for pregnant women who presented to an acute care setting with a migraine attack and received neurology consultation between 2009 and 2014.

Results We identified 72 pregnant women with migraine who were treated with pain medications. Fifty-one percent (37/72) were in the third trimester of pregnancy, 39% (28/72) in the second trimester, and 10% (7/72) in the first trimester. Thirty-two percent (23/72) had not tried any acute medications at home before coming to the hospital, and 47% (34/72) presented in status migrainosus. Patients received treatment in the hospital for a median of 23 hours (interquartile range = 5–45 hours). The most common medications prescribed were metoclopramide in 74% (53/72) of patients (95% confidence interval [CI] 62–82%) and acetaminophen in 69% (50/72) of patients (95% CI 58–79%). Metoclopramide was administered along with diphenhydramine in 81% (44/53) of patients (95% CI 71–91%). Acetaminophen was the most frequent medicine administered first (53%, 38/72). Patients were often treated with butalbital (35%, 25/72) or opioids (30%, 22/72), which were used as second- or third-line treatments in 29% of patients (20/72). Thirty-eight percent (27/72) received an intravenous (IV) fluid bolus, 24% received IV magnesium (17/72), and 6% (4/72) had peripheral nerve blocks performed.

Conclusions While the majority of pregnant women with acute migraine received medications considered relatively safe in pregnancy, there was variation in treatment choice and sequence. Some acute medications considered potentially hazardous for fetal health and less effective for migraine (opioids and butalbital) were used frequently, whereas other treatments that may have low teratogenic risk (nerve blocks, IV fluid boluses, and triptans) were used less or not at all. These results indicate a need for developing guidelines and protocols to standardize acute treatment of migraine in pregnancy.


Migraine is a common problem among pregnant women, with prevalence in pregnancy reported as high as 35%.[1] While migraine typically improves during pregnancy,[2,3] many women have a stable or worsening course and may even experience first-time migraine attacks.[4,5] Twenty-six percent of women with migraine during the first trimester of pregnancy report moderate or severe headache-related disability.[6]

Despite the high prevalence of migraine, acute treatment of migraine can be difficult during pregnancy, because of lack of medication trials and fears of teratogenicity. Based on large population survey-based studies, approximately one-half to three-quarters of pregnant women with migraine report using acute medications in pregnancy,[7] but less than one-third consider their headaches optimally treated during this time,[8] and nearly half report receiving conflicting information about safety of migraine medications in pregnancy.[9]

With limited medication options, many pregnant women with migraine may present to acute care and emergency department (ED) settings for treatment. Around half of women presenting with headache to acute care are ultimately diagnosed with migraine.[5,10] While guidelines exist for acute management of migraine in the ED,[11] there are currently no guidelines for treating migraine in pregnancy. In both inpatient and outpatient settings, little is known about what medications are commonly prescribed for pregnant women with migraine, because while several studies have investigated analgesic use among pregnant women with migraine,[7,9,12] no study has specifically and directly examined physicians' prescribing practices in this population.

Given the paucity of data on acute medication administration for migraine in pregnancy, we aimed to characterize the treatment of pregnant women with migraine in an acute care setting using a database of pregnant women presenting to our institution with headache.