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Migraine Management and Pregnancy

Pregnancy – Migraine Treatment Challenges – Acceptable Drugs

Challenges of Migraine Treatment during Pregnancy

Pregnancy effect on migraine severity is rather positive. Migraine attacks are worse in the first trimester and are lighter in the second and the third trimesters.

This effect of pregnancy on migraine severity is observed only in migraine without aura and in women with menstrual association of the attacks.

Overall, about 60% to 70% women suffering migraine report fewer attacks during pregnancy. Breastfeeding prolongs positive effects of pregnancy on migraine.

Migraineurs suffering migraine with aura report no change in migraine pattern during pregnancy. Meanwhile, pregnancy may bring up the first migraine attack with aura.

Migraine has no effect on the fetus, but it does increase the chance of stroke in the and pregnancy related hypertension syndromes in the mother.

A general rule of any disease management during pregnancy and breastfeeding is avoiding any medications if possible. On the other hand, it hard to do nothing about severe headaches. The first step in management is avoiding known triggers: stress, dehydration, skipped meals, irregular sleep pattern, and excessive or insufficient physical activity.

Symptomatic Migraine Treatment during Pregnancy

Acetaminophen during Pregnancy and Lactation
Acetaminophen is a drug of choice during pregnancy and breastfeeding. Multiple studies confirm safety of therapeutic doses (no more than 4 grams per day).
Unfortunately, acetaminophen often fails to relieve migraine headache.

NSAIDs during Pregnancy and Lactation
All NSAIDs (nonsteroidal anti-inflammatory drugs) are contraindicated in the third trimester due to well-known fetal complications: premature closure of ductus arteriosus and oligohydramniosis.
Aspirin has additional risk of bleeding, especially in relation to delivery and it may prolong labors.
NSAIDs preferred during the first two trimesters are Ibuprofen, Naproxen, and Diclofenac. None is safe in the third trimester.
During breastfeeding shorter acting NSAIDs, Ibuprofen and Diclofenac are recommended. Aspirin is not recommended during lactation due to potential theoretical risk of Raye syndrome in the baby.

Triptans during Pregnancy and Lactation
There is no evidence of negative effects of Sumatriptan on the pregnancy outcome in humans. At the same time, no data confirming safety is available either. Sumatriptan is considered acceptable for migraine attacks, providing safer alternatives are ineffective.
Very little sumatriptan gets into the breast milk.
Information about other Triptans is limited.

Antiemetics during Pregnancy and Breastfeeding
Antiemetics (suppressants of nausea and vomiting) are well known for their efficiency in migraine attack treatment. They may stop migraine attack either alone or in combination with NSAIDs.
Metoclopramide (Reglan), Prochlorperazine (Compazine), and Promethazine (Phenergan) are often used during pregnancy. Metoclopramide (Reglan) safety during pregnancy is proven the most.

Ergots during Pregnancy and Breastfeeding
Ergotamine and Dihydroergotamine are contraindicated during pregnancy and lactation due to increased risks of miscarriage and side effects in breastfed infants.

Barbiturates and Narcotics during Pregnancy
Both have questionable benefits in migraine management and are not recommended in pregnancy for various reasons.

Migraine Prophylaxis and Pregnancy

Pregnancy substantially limits drug choices for migraine and other primary headaches prevention.

Propranolol during Pregnancy
Propranolol is a drug of choice for migraine prevention during pregnancy and breastfeeding. No proven harm to the baby, no proven safety either. Propranolol has to be stopped a few days prior to delivery in order to avoid sluggish uterine contractions and slow heart rate in the newborn.

Amitriptyline (Elavil) and Nortriptyline (Pamelor) during Pregnancy
There is no evidence of birth defects caused by low doses from 10 mg to 50mg per day in humans. Safety is not established. In order to avoid typical side effects in the newborn it might be reasonable tapering them off a few weeks prior to delivery.
Use of these medications during lactation is OK, since very little drug gets into the breast milk.

Antiepileptic Drugs for Migraine in Pregnancy
Both Topamax and Valproate are limited only to epilepsy treatment during pregnancy. They are contraindicated for migraine prophylaxis. Topamax causes cleft palate and lip. Valproate is known to cause multiple types of birth defects.
During lactation, however, they are both acceptable due to low concentration in the breast milk.

Angiotensin Receptor Blockers (e.g. Candesartan)
Angiotensin-converting Enzyme Inhibitors (e.g. Lisinopril)

Some doctors use those for migraine prevention. They have been reported causing multiple birth defects if taken in the second and third trimesters. Even though negative effects on the fetus were not reported during the first trimester, I would suggest avoiding these groups of medications during pregnancy.
No data available about their use during breastfeeding.

Botox during Pregnancy and Lactation
No data is available on safety of Botulinum Toxin injections during pregnancy and lactation.

Verapamil and Lithium during Pregnancy and Lactation
Neither of these medications has any use in migraine prevention. Meanwhile they are the most effective drugs for cluster headache management.
Lithium is contraindicated during pregnancy and lactation due to birth defects and side effects in breastfed infants.
Verapamil is not associated with known birth defects, but it might affect uterine contraction ability. It does get into the breast milk and may cause side effects in the infant.
Considering severity of pain syndrome in cluster headache, Verapamil remains a decent choice for this condition during pregnancy. According to statistics women tend to avoid pregnancy after development of cluster headaches. Headache management issues might be one of the reasons.

Oxygen inhalation, as an abortive treatment option in cluster headaches, is not known to cause any problems during pregnancy.
Sumatriptan and Occipital Nerve Block could be considered as well.

Conclusion and Disclosure on Migraine During Pregnancy

No drug can be considered 100% safe during pregnancy.

Since we don’t live in the ideal world, medications often have to be used even during pregnancy.
This article is only an educational tool. Don’t consider the information provided as a set of instructions for migraine and cluster headaches treatment during pregnancy.

You still have to discuss all available headache management options with your doctor.


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