Treating Migraine During Pregnancy

How to treat patients for migraine during pregnancy

It’s important for providers who treat women during their reproductive years to be aware of treatment options that are safe during pregnancy. Many women with migraine who are pregnant or considering pregnancy stop taking their migraine medications and assume they don’t have safe treatment options available—but this is simply not true.

Women typically start to experience migraine attacks during adolescence, which aligns with when menstruation begins. The highest incidence of migraine is between ages 18 and 44, which are also the year many women experience pregnancy. The rate of migraine among women is three times higher than it is for men. Because of these figures, it is believed that fluctuations in estrogen levels play a role in migraine development.

Dr. Tracy Grossman, an obstetrician-gynecologist who has completed a fellowship in maternal-fetal medicine and earned a master’s in neuroscience, shares the range of treatment options available for pregnant patients with migraine.

Treatment Options During Pregnancy

Certain medications used for migraine treatment and prevention are contraindicated for pregnancy, due to safety concerns for the developing fetus. For patients who use oral contraceptives to regulate their hormone levels and manage migraine, having a conversation about migraine treatment options may happen when they want to go off of birth control and start trying to conceive. The good news is there are safe options for migraine prior to and during pregnancy.

“I’m always telling my patients, either preconception or patients that are pregnant, that we recommend in general to use the [fewest] number of different medications for anything that we’re treating,” Dr. Grossman says. “And also, of course, the lowest dose possible that we can use in pregnancy and preconception is what we recommend.” Her first-line treatment is non-medication options, and she then layers in other treatments as needed.

Non-medication options

• Hydration: Staying hydrated is important for all pregnant women, but especially for those with migraine. “Typically a lot of patients are dehydrated and don’t even realize it,” says Dr. Grossman.
• Caffeine: Many women decide to cut out caffeine completely when they become pregnant, but a low level of caffeine is considered safe and can help prevent migraine. Dr. Grossman suggests about a cup to a cup and a half of coffee per day, with a daily maximum of 200 milligrams of caffeine.
• Magnesium: Magnesium is a supplement commonly used for migraine prevention. With its low risk of side effects, it is safe to use during pregnancy.

Over-the-counter medications

Over-the-counter medications, like acetaminophen, are safe during pregnancy. In combination with non-medication options, it can be effective in preventing and managing migraine symptoms.

Non-steroidal anti-inflammatories are another option for relieving migraine. “These are things like naproxen, Toradol, ibuprofen, which we don’t recommend use in the first trimester or in the third trimester, but in the mid-second trimester are considered safe to use for a limited amount of time,” says Dr. Grossman. “I would have a patient be on one of these medications for about 48 hours, no more than that.”

Prescription medications

Many women with migraine take triptans prior to pregnancy, but then decide to discontinue the prescription medication when they become pregnant or their provider recommends that they stop taking it. Despite older studies that cited concern for fetal growth restriction and increased blood loss at delivery, new research shows that it’s not necessary to stop using triptans while pregnant. “More recent studies have shown that sumatriptans or triptans are actually very safe in pregnancy and have not been associated with any congenital defects or pregnancy complications,” Dr. Grossman says.

Some anti-nausea medications, including prochlorperazine, metoclopramide and diphenhydramine can also relieve migraine symptoms. Though they’re typically not used for prolonged amounts of time, these medications are safe in pregnancy.

Procedures/Devices

Nerve blocks can give patients relief from migraine during pregnancy. These local injections of a substance like lidocaine or bupivacaine are injected into the scalp to target specific nerves. The location of the injection depends on the type and location of the patient’s migraine. “These are considered safe in pregnancy because it’s a local injection, the medication, not a systemic administration,” says Dr. Grossman, who did a study on peripheral nerve blocks during her residency. The nerve blocks can be used repeatedly throughout pregnancy as a prevention or treatment measure.

Liquid lidocaine 4% can also be administered as a nasal spray. It is safe for patients to use as often as a couple of times a day. Patients may also benefit from a wearable neuromodulation device that emits a mild electrical current for migraine relief or prevention. You can learn more about device options and how to select the best one for your patient here.

Recommending one type or a combination of prevention and treatment options can help your migraine patients safely manage their symptoms throughout pregnancy.

Primary care practitioners are essential to identifying and treating headache disorders. The American Headache Society’s First Contact – Headache in Primary Care program provides educational resources to empower healthcare professionals and improve headache and migraine care. Learn more about the program here.