Managing Migraine During Pregnancy

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Fortunately, migraines improve for most women during pregnancy. This is especially true for women who have migraine without aura. The high and fairly steady levels of estrogen during pregnancy help to protect against migraine. However, not all women’s migraines improve during pregnancy. Therefore, it is important to have a treatment plan in place. This plan should be developed with the help and approval of your treating obstetrician. Consulting with a headache specialist or your primary care provider may be necessary as some obstetricians are not comfortable evaluating and treating migraine.

Ideally, a treatment plan for managing migraines during pregnancy begins prior to the pregnancy itself. The treatment plan should include:

  1. What to take for acute migraine attacks during pregnancy?
  2. What can be taken to prevent migraine attacks during pregnancy?
  3. What are some of the non-pharmacologic treatments that can help during pregnancy?

There are no established or published guidelines for treatment migraine during pregnancy. I am in charge of a committee in American Headache Society that is developing guidelines for the treatment of migraine during pregnancy. The project is not yet complete. Here is what I can tell you:

Acute Treatment of Migraine Attacks in Pregnancy

  1. Tylenol (acetaminophen)
  2. Caffeine( in moderation may help alleviate acute migraine attack)
  3. Anti-nausea medications (such as Zofran, Reglan, and Phenergan)
  4. Tylenol with Codeine; Vicodin (hydrocodone); Fioricet (Butalbital) to rescue if severe migraine attack
  5. IV (Intravenous) fluids
  6. IV Magnesium; IV Cortisone; IV Zofran or Reglan in some cases
  7. Triptans such as Imitrex ONLY if approved by your obstetrician

The above list is only meant to be a guide; each obstetrician may have their preferred medications for use during pregnancy. The following medications should, in most cases, be avoided during pregnancy:

  1. Aspirin
  2. Anti-inflammatories such as Motrin (Ibuprofen) and Aleve (Naproxen)
  3. Ergotamines such as Cafergot; Ergostat; and Migranal Nasal Spray
  4. Excessive use of narcotics such as hydrocodone

Preventive treatment during pregnancy can include the following

  1. Biofeedback
  2. Acupuncture
  3. Physical Therapy
  4. Massage
  5. Stress-reduction Exercises
  6. Keeping hydrated
  7. Eating a balanced diet; not skipping meals
  8. Exercising regularly

If non-pharmacologic treatment is not sufficient to prevent migraines during pregnancy, then the beta-blockers such as labetolol and propanolol are sometimes used. A brief course of an oral prednisone can be useful in some cases to “break” a prolonged migraine attack.

Drugs to avoid for prevention during migraine include

  1. Depakote
  2. Topamax (recent association with increased risk of cleft palate)
  3. ACE inhibitors and ARB’s (both types of blood pressure medications)

A procedure called an occipital nerve block can useful during pregnancy for a prolonged migraine attack. An anesthetic is injected superficially in the back of the head in the “occipitalis” region of the posterior scalp. In my office I use bupivacaine. It can often bring immediate relief for a migraine patient and can help for 1-2 weeks. The anesthetic does not get into the blood system and would not affect the fetus.

In summary, there are many treatment options for the pregnant female who is suffering with migraines. Keeping a healthy life-style and being aware of non-pharmacologic treatment options such as acupuncture and biofeedback can help lessen the need for prescription medications.

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