Cluster Headaches During Pregnancy: What Do You Do?

I've always known there was a possibility that I would experience cluster headaches during pregnancy. I've been pregnant twice before, but sadly have no living children yet.

Cluster headache and pregnancy

Cluster headaches are a different type of demon than migraine disease, and according to women and headache specialists I have interviewed, there seems to be a 50/50 chance that episodic cluster headache patients will have attacks during pregnancy. One woman told me the only reason she didn't commit suicide during the second trimester during an attack was that she wanted to meet her daughter. My first two pregnancies didn't make it past the first trimester, but I was blissfully pain-free with both of them. This pregnancy with my daughter, Lucy, is a different story.

Managing cluster headache and migraine during pregnancy

There were some migraine attacks during the first 13 weeks, which never lasted longer than a day, and I was able to avoid taking any medications for them. But the cluster headaches aren't as straightforward. At the dawn of my 14th week of pregnancy, I awoke at 7 am with the familiar stabbing pain in my right temple behind my eye. Those first few seconds of the attack came with an inner monologue: Is this just a shadow? What if it's the start? Then some inner voice found me, saying, It's okay, you've prepared for this. And I had, to a certain extent. I reached for my oxygen tank, and the attack ended a few minutes later, followed by an evening attack around 6 pm. The next few days followed the same pattern of two attacks, one in the early morning and one at the end of my day when I started to relax.

Should I take medications for cluster headache while pregnant?

Taking medications during pregnancy can be a difficult choice, especially when I'm an avid researcher and read the studies. That hard decision is compounded when you consider that OBGYNs and primary care doctors are hesitant to offer women any treatment options for headache disorders during pregnancy. There is always the risk-benefit ratio to weigh, but a lot of pregnant women aren't given the information they need to make that informed choice. We're often given the impression that we must suffer through it for the health of the baby. Still, maternal health and management of diseases throughout pregnancy is a vital part of reaching that beautiful moment where mommy meets baby for the first time. A common saying goes, "A happy momma is a happy baby." 

What treatment options are available during pregnancy?

The severe, sudden onset of cluster headache attacks takes away my option of saying no to treatment. Luckily, high-flow oxygen is perfectly safe to abort attacks during pregnancy, but what other options are there? What if I was part of that small percentage of folks who don't respond to oxygen therapy? The alternative treatments that often work miracles for cluster headaches such as psilocybin mushrooms have been linked to early miscarriage and, for obvious reasons, aren't recommended during pregnancy.

Using oxygen and nasal medications for cluster headache

According to a 2010 study, high-flow oxygen is the "most appropriate" treatment to abort attacks in pregnant patients, as well as first-line for anyone with cluster headaches. Oxygen therapy was followed by nasal spray sumatriptan and nasal lidocaine, which are Pregnancy Category B drugs, meaning, "Animal reproduction studies have failed to demonstrate a risk to the fetus, and there are no adequate and well-controlled studies in pregnant women." Nasal spray sumatriptan is not ideal to abort cluster headache attacks quickly as the injectable form works faster and more effectively. However, the nasal spray can still offer relief in 15-20 minutes.1,2

Verapamil, steroids, and melatonin

The same study stated Verapamil and steroids are the preferred preventive treatment options in pregnant patients. Still, both of them are Category C, meaning “Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks." However, the study did not mention melatonin, a vitamin supplement commonly used at nighttime as a preventive treatment for cluster headaches. This is theorized to work because melatonin production is in the pineal gland and involved in circadian rhythms, which is disrupted and decreased in cluster headache patients.

Is melatonin safe to take during pregnancy?

Hormones and changing seasons have a fascinating impact on cluster headaches, and melatonin can be a highly beneficial preventive treatment with fewer side effects than Verapamil and steroids. Melatonin use during pregnancy seems to depend on the provider and the study. It's often used to promote better sleep, whether you're pregnant or not, and some research shows taking a melatonin supplement can improve outcomes in compromised pregnancies.3,4

How do they know what medications are safe for pregnant women?

Keep in mind that it's unethical to study the effect of medications and treatments on pregnant women in a typical manner, so medical professionals rely on interviews with women throughout their pregnancies and data on maternal and fetal outcomes to come up with pregnancy-safe treatment guidelines. If you're pregnant and taking medication, I highly recommend joining a patient study so your experience can be added to the pool. Never start or stop a medication or treatment without speaking to your doctor first.

Oxygen for cluster headache

A 3.5-foot tall oxygen tank lives next to my bed for now. So far, the high-flow oxygen followed up with low-flow for 20 minutes has given me fast relief for cluster headache attacks during pregnancy. I feel lucky that oxygen works so well for me, and it's good to know that I have other options out there should they increase to four or more attacks per day, which is a typical cycle for me.

The hormones of pregnancy will likely swing in my favor again in the third trimester. All of the pain and losses in the past will be worth it when I hold my sweet Lucy this November.

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