Migraine & Pregnancy: What to Expect
For the majority of women with migraine, they can expect their migraines to greatly improve during pregnancy. This improvement is felt to be linked to the high steady-state levels of estrogen that are achieved by the second trimester. Many women in my practice report they had no migraines during their pregnancies and comment that they wish they could stay pregnant all the time!
However, for some women, their first migraine or other severe headache may occur with pregnancy. Importantly, not all severe headaches during pregnancy are migraine. A recent article published in the journal The Obstetrician and Gynecologist1stated that 90% of headaches during pregnancy are migraine or tension. The other 10% can be attributable to the following:
- Pre-eclampsia (disorder of pregnancy characterized by high blood pressure and protein in the urine)
- Idiopathic intracranial Hypertension (increase in pressure of cerebrospinal fluid that surrounds our brain and spinal cord)
- Cerebral Venous Thrombosis (CVT)-blood clot in the sinuses that drain blood from the brain
Therefore, new-onset headache during pregnancy needs to be carefully evaluated and in most cases , will require an MRI of the brain, possibly an MRV to evaluate the venous system if CVT is suspected, and a spinal tap with opening pressure measurement if idiopathic intracranial hypertension is suspected.
If the headaches are determined to be migraine during pregnancy, then the choice of treatment needs to be carefully chosen to protect the developing fetus. Medications felt safe during pregnancy for the majority of women include acetaminophen (Tylenol), caffeine in small amounts, magnesium (can be used both to treat and prevent migraine), and B-2 (Riboflavin) for prevention. For severe migraines, some OB/GYN’s feel comfortable using a triptan like Sumatriptan (Imitrex) whereas others prefer a narcotic such as Hydrocodone (Vicodin) for rescue if necessary. Odansetron (Zofran) used to be considered safe to treat nausea, including the nausea of migraine, during pregnancy but recent published reports looking at large numbers of women in the Danish Birth Registry show a very small but slight increase risk in congenital heart defects, cleft palate, and serotonin syndrome.2 As a result, the FDA has issued a warning about the use of Zofran during pregnancy. A safer option to treat nausea during pregnancy would be Diclegis, a combination of Doxylamine succinate (Unisom) and pyridoxine hydrochloride (Vitamin B-6). It can be dose up to 4 tablets a day. Diclegis is a Pregnancy Category A rating (the safest rating possible).
For a severe migraine during pregnancy, a safe treatment option would include a Liter of fluids (Normal Saline in most cases) and Magnesium 1-2 grams by IV. As a headache specialist, I may also be comfortable giving 4 grams of Zofran by IV since despite the recent warning issued by the FDA, there was a very good article published in the New England Journal in 2013 which looked at over 600,000 pregnancies in Denmark and found no increase risk in birth defects and no increase risk in spontaneous abortion.3 With any medication used during pregnancy, the benefits have to weighed against the risks. With a severe migraine, dehydration would pose a major risk to both the fetus and mother so in my opinion, IV or oral Zofran may be appropriate in some cases. I may also use steroids, either oral or IV, to break a severe or prolonged migraine in a pregnant patient.
Other treatment options for migraine during pregnancy include acupuncture, physical therapy, massage therapy, occipital nerve blocks, and possibly for some, the new Cefaly headband. The Cefaly Headband is the first FDA approved device for migraine in the United States. It is similar to a TENS unit (transcutaneous nerve stimulator) and can be useful for migraine. In the United States it is FDA approved for prevention only and is meant to be worn for 20 minutes once a day. To learn more, go to www.Cefaly.com.
In summary, for most women with migraine, their headaches are expected to improve during pregnancy. If headaches begin for the first time during pregnancy or worsen significantly, then a work-up for a secondary headache may be needed. If the headache during pregnancy is diagnosed as migraine, there are treatment options available. In all cases, the treatment plan needs to take into consideration benefits and risks for both the mother and fetus.
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