Migraine Treatment in Pregnancy

Migraine treatment during pregnancy can be challenging due to concerns about the safety of medications for both the mother and the developing fetus.

The treatment approach may vary depending on the severity and frequency of migraines, as well as the trimester of pregnancy.

Migraine Treatment in Pregnancy

Here are some general principles for migraine treatment in pregnancy:

Lifestyle modifications

Non-pharmacological approaches may help reduce the frequency and severity of migraines. These approaches are considered the first line and include:

• getting enough sleep,
• eating a healthy diet,
• staying hydrated,
• avoiding triggers such as certain foods or stressors, and
• practicing relaxation techniques such as yoga or meditation.

Acute migraine treatment in pregnancy:

Over-the-counter pain relievers such as acetaminophen (Tylenol) are generally considered safe for short-term use during pregnancy.

Nonsteroidal anti-inflammatory drugs (NSAIDs) or triptans should be avoided or used only if recommended by a healthcare provider.

In some cases, opioids or anti-nausea medications may be prescribed for acute migraine treatment, but their use should be limited due to the risk of adverse effects.

Preventive migraine treatment in pregnancy:

If a pregnant woman experiences frequent or severe migraines, her healthcare provider may recommend preventive medications. Options may include medications such as:

• beta-blockers,
• calcium channel blockers, or
• antidepressants that have been shown to be safe during pregnancy.

Alternative approaches such as acupuncture or biofeedback may also be considered.

It’s important to note that the safety of medications during pregnancy can vary depending on the specific medication, the dose, and the trimester of pregnancy.

Pregnant women should always consult with their healthcare provider before taking any medication or starting any treatment for migraines.

Fetal and maternal complications of migraine during pregnancy:

Women with migraine headaches are more at risk of developing complications during pregnancy. Here’s a table of potential fetal and maternal complications associated with migraine during pregnancy:

It’s important to note that not all women with migraine during pregnancy will experience these complications.

Acute treatment of migraine attack during pregnancy:

Acute migraine headaches in pregnancy may be self-limiting and require only rest or massage. However, it can be severe enough that medications may not be avoidable.

Most drugs are taken with caution during pregnancy. Some options for the acute treatment of migraines during pregnancy are:

• Acetaminophen (Tylenol):

This over-the-counter pain reliever is generally considered safe for short-term use during pregnancy. It can help relieve mild to moderate migraine pain.

• Ice packs:

Applying a cold compress to the forehead or neck may help alleviate migraine pain.

• Relaxation techniques:

Deep breathing, meditation, and other relaxation techniques can help reduce stress and tension that can trigger migraines.

• Caffeine:

Small amounts of caffeine, such as a cup of coffee, may help relieve migraine symptoms by constricting blood vessels and reducing inflammation. However, pregnant women should limit their caffeine intake to no more than 200 mg per day.

• Prescription medications:

Some prescription medications, such as opioids or anti-nausea medications, may be used to treat severe migraines during pregnancy.

However, these medications should be used only if recommended by a healthcare provider and for the shortest possible duration due to the risk of adverse effects.

It’s important to note that nonsteroidal anti-inflammatory drugs (NSAIDs) and triptans should be avoided during pregnancy, as they can be harmful to the developing fetus.

Safety of migraine preventive medicines during pregnancy

Preventive medicines used to treat migraine are usually avoided during pregnancy as intake of any medicine for an extended period during pregnancy may increase the risk of adverse fetal outcomes.

However, sometimes it is necessary to take preventive therapy so as to avoid acute attacks. Here is a list of medications used for the prevention of migraines during pregnancy that are safe/unsafe:

It’s important to note that the safety of medications during pregnancy can vary depending on the specific medication, the dose, and the trimester of pregnancy.

Are CGRP antagonists safe for use during pregnancy?

The safety of CGRP (calcitonin gene-related peptide) antagonists and CGRP monoclonal antibodies during pregnancy is not well established. These medications have not been extensively studied in pregnant women, so the potential risks to the developing fetus are not fully known.

There have been some animal studies that suggest that CGRP agonists may be harmful during pregnancy. For example, one study in pregnant rats found that CGRP agonists caused fetal growth restriction and decreased fetal weight.

Because of these uncertainties, CGRP antagonists are generally not recommended for use during pregnancy.

If a pregnant woman is currently taking a CGRP agonist for migraine prevention, she should consult with her healthcare provider about the risks and benefits of continuing the medication during pregnancy.

List of CGRP antagonists and monoclonal antibodies:

It’s important to note that the safety and efficacy of these medications can vary depending on the specific medication, the dose, and the individual patient. These medications should only be used under the guidance of a healthcare provider.

Medical devices that are considered safe during pregnancy:

There are some medical devices that may be considered safe for use during pregnancy to manage migraines. Here are some examples:

• Cefaly:

The Cefaly device is a non-invasive nerve stimulation device that has been cleared by the FDA for the preventive treatment of migraines. It is generally considered safe for use during pregnancy.

• Occipital nerve stimulators:

Occipital nerve stimulators are implantable devices that provide electrical stimulation to the occipital nerves, which are involved in migraine pain.

While there is limited data on the safety of occipital nerve stimulators during pregnancy, they may be considered for women who have severe migraines that are not well controlled with other treatments.

• Transcranial magnetic stimulation (TMS):

TMS is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain. It has been used off-label to treat migraines and is generally considered safe for use during pregnancy.

Botox for migraine treatment during pregnancy

The safety of using Botox (botulinum toxin) for migraine treatment during pregnancy has not been established, and there is limited data on the potential risks to the developing fetus.

Botox is a type of medication that works by blocking the release of certain chemicals in the nervous system that cause muscle contractions. It is approved by the FDA for the prevention of chronic migraine in adults.

Although Botox is not absorbed systemically, it is possible that it could cross the placenta and affect the developing fetus.

There have been some reports of adverse events associated with the use of Botox during pregnancy, including fetal abnormalities and premature delivery.

Due to the lack of safety data, it is generally recommended that Botox be avoided during pregnancy. If a woman is currently receiving Botox treatment for chronic migraine and becomes pregnant, she should discuss her options with her healthcare provider.

In some cases, it may be appropriate to discontinue the Botox treatment, while in others, it may be necessary to continue the treatment if the benefits outweigh the potential risks.

Migraine Treatment in Pregnancy: ACOG Recommendations:

The American College of Obstetricians and Gynecologists (ACOG) has published recommendations for the treatment of migraine during pregnancy. These recommendations include:

• Non-pharmacologic treatments:

Non-pharmacologic treatments, such as stress reduction techniques, sleep hygiene, and dietary modifications, should be considered as first-line therapy for migraines during pregnancy.

• Acute treatment of migraines:

For acute treatment of migraines during pregnancy, acetaminophen is generally considered safe and effective.

Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided during the third trimester due to the risk of fetal harm.

Triptans should be used with caution and only after consultation with a healthcare provider.

• Prevention of migraines:

For the prevention of migraines during pregnancy, magnesium supplementation may be considered.

Beta-blockers and tricyclic antidepressants should be used with caution and only after consultation with a healthcare provider.

Other medications, such as topiramate, valproic acid, and Divalproex, should be avoided due to the risk of fetal harm.

• Referral to a headache specialist:

Women with severe migraines or migraines that are not well-controlled with conservative measures should be referred to a headache specialist for further evaluation and management.

It’s important to note that the recommendations may vary depending on the individual patient and the severity of their migraines.

Women with migraines who are pregnant or planning to become pregnant should discuss their treatment options with their healthcare provider.

What are the best migraine relief drugs during the first trimester of pregnancy?

During the first trimester of pregnancy, it is important to be cautious when taking any medication, as this is a critical time for fetal development. Non-pharmacologic treatments should be considered as first-line therapy for migraines during pregnancy.

If medication is necessary, acetaminophen (paracetamol) is generally considered safe and effective for the treatment of migraines during the first trimester.

It is important to follow the recommended dosage and not exceed the maximum daily dose. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen should be avoided during the first trimester due to the risk of fetal harm.

What are the best migraine relief medicines during the second & third trimesters?

During the second and third trimesters of pregnancy, it is still important to be cautious when taking any medication. It is preferred to use non-pharmacologic treatments to avoid any complications.

If medication is necessary, acetaminophen (paracetamol) can be used. Other medications include antiemetic and antihistamines such as Metoclopramide Prochlorperazine Promethazine.

The use of Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen should be avoided as these medications are associated with the risk of premature closure of the fetal ductus arteriosus, which can lead to fetal harm.  [ref]

Triptans, which are a class of medications specifically used for the treatment of migraines, should be used with caution during pregnancy and only after consultation with a healthcare provider.

Sumatriptan, which is a commonly used triptan for migraine relief, has been studied in pregnancy and has not been associated with an increased risk of birth defects. However, the safety of other triptans during pregnancy has not been fully established.

Summary of the best migraine relief medicines according to the trimesters of pregnancy:

Here’s a table of commonly recommended medications for migraine relief during each trimester of pregnancy:

When to worry about migraines during pregnancy?

Pregnant women with migraines should discuss their symptoms with their healthcare provider and be aware of certain warning signs that may indicate a need for medical attention.

Some warning signs that may indicate a more serious issue related to migraines during pregnancy include:

• Severe or worsening headaches that do not respond to over-the-counter pain relievers or other treatments
• Changes in vision, such as blurred vision, double vision, or loss of vision
• Severe nausea or vomiting that does not improve with anti-nausea medications or other interventions
• Severe abdominal pain or cramping
• Swelling in the hands, feet, or face, which may be a sign of preeclampsia

If a pregnant woman with migraines experiences any of these symptoms, she should seek medical attention right away.

Additionally, report any changes in fetal movement or signs of preterm labor to your healthcare provider.

It’s important for pregnant women with migraines to receive regular prenatal care and work closely with their healthcare provider to manage their condition.

Pregnancy Headaches Vs Migraine Headaches:

Pregnant women may develop migraine headaches during pregnancy and consider them pregnancy-associated headaches. Because the treatments differ, it is best to understand the difference between the two.

Here’s a table comparing the similarities and differences between pregnancy headaches and migraines:

It’s important to note that not all headaches during pregnancy are pregnancy headaches, and not all headaches that occur during pregnancy are migraines.