Migraine and Pregnancy

This article addresses questions most frequently asked by women with migraine who are planning a pregnancy.  Please consult your own physician if you are pregnant or are planning a pregnancy.

I’m pregnant…but what’s going to happen to my migraine?

Results from studies suggest that at least 70% of women who have migraine without aura experience improvement in migraine during pregnancy, particularly during the second and third trimesters.1-4 Since migraine without aura is often associated with falling levels of oestrogen, the reason for improvement in pregnancy is often considered to be the more stable levels of oestrogen. However, there are many physical, biochemical, and emotional changes in pregnancy that could also account for improvement, including increased production of natural painkillers known as endorphins, muscle relaxation, and changes in sugar balance. In contrast to migraine without aura, attacks of migraine with aura follow a different pattern during pregnancy as attacks are more likely to continue and aura may develop for the first time.5-7

I’m pregnant…but is migraine going to harm my baby?

There is no evidence that migraine, either with or without aura, affects the risk of miscarriage, stillbirth or congenital abnormalities over and above the expected outcome for pregnancy in women without migraine.5,8

I’m pregnant…but what can I take to treat my migraine?

Drugs tend to exert their greatest effects on the developing baby during the first month of pregnancy, often before the woman knows she is pregnant. Hence take as few drugs as possible, in the lowest effective dose. Although many of the drugs taken by unsuspecting women rarely cause harm, there is a difference between reassuring the pregnant woman that what she has taken is unlikely to have affected the pregnancy and advising her what she should take for future attacks. Most evidence of safety is circumstantial; few drugs have been tested during pregnancy and breastfeeding because of the obvious ethical limitations of such trials. Hence drugs are only recommended if the potential benefits to the woman and baby outweigh the potential risks.

Non-drug treatment

Many pregnant women favour non-drug methods of management during pregnancy, particularly once they are aware that migraine is likely to improve with time. Early pregnancy symptoms such as sickness, particularly if severe, can reduce food and fluid intake resulting in low blood sugar and dehydration, aggravating migraine. Simple advice to eat small, frequent carbohydrate snacks and drink plenty of fluids may help both problems. Adequate rest is necessary to counter overtiredness, particularly in the first and last trimesters. Other safe preventative measures that can be tried include biofeedback, yoga, massage, and relaxation techniques. The benefits of these methods can last longer than the pregnancy!

Drugs to treat the symptoms of migraine

Pain killers

Most painkillers are safe to use in pregnancy. However, check with your doctor, particularly if you are getting headaches more often than a couple of days a week. Paracetamol (acetaminophen) is the drug of choice in pregnancy, having been used extensively without apparent harm to the developing baby.9 Aspirin has been taken by many pregnant women in the first and second terms of pregnancy.9, 10 However, it should be avoided near the expected time of delivery since it can increase bleeding. Codeine: Codeine is not generally recommended for the management of migraine in the UK.11 However, occasional use in doses found in combined analgesics is unlikely to cause harm. Ibuprofen: can be taken in doses not exceeding 600 mg daily.9

Antisickness drugs

Buclizine, chlorpromazine, domperidone (not available in the U.S), metoclopramide and prochlorperazine have all been used widely in pregnancy without apparent harm.

Triptans

Data from the large sumatriptan safety database, where inadvertent exposure to sumatriptan during pregnancy has occurred, are reassuring.12 However, continuing triptans during pregnancy is not recommended.

Ergots

Ergotamine should not be used during pregnancy as it can increase the risk of miscarriage and perinatal death.

Drugs to prevent migraine

If daily medication is considered necessary to prevent migraine during pregnancy, the lowest effective dose of propranolol is the drug of choice.9 Amitriptyline is a safe alternative.9 There are no reports of adverse outcomes from pizotifen (not available in the U.S.) used during pregnancy or lactation, although it is less often used than the drugs above. In contrast, sodium valproate, increasingly used for migraine prophylaxis, should not be taken during pregnancy in the absence of epilepsy as there is a high risk of fetal abnormalities.13 Indeed, women prescribed sodium valproate for migraine must use effective contraception. In general, other anti-epileptic agents prescribed for migraine prophylaxis cannot justifiably be recommended during pregnancy on the basis of currently available evidence.

I’m pregnant…but I got these funny blind spots with my migraine – should I see my doctor?

It is not uncommon for a woman to have her first attack of migraine aura during pregnancy. Symptoms are typically bright visual zig-zags growing in size from a small bright spot and moving across the field of vision over 20-30 minutes before disappearing. A sensation of ‘pins and needles’ moving up an arm into the mouth may accompany this. If you experience these typical symptoms and your doctor confirms that this is migraine, there is no need to be concerned and no tests are necessary. However, if the symptoms are not typical for migraine aura, it is important to exclude other disorders, such as blood clotting disorders or high blood pressure, which may occasionally produce symptoms not dissimilar from migraine.

What’s going to happen to my migraine after I have the baby?

If migraine has improved, this will usually continue until periods return. However, a bad attack of migraine can occur within a couple of days of delivery. This may be because of the sudden drop in oestrogen that occurs.14 Exhaustion, dehydration and low-blood sugar are other possible causes.

What can I take to treat my migraine if I’m breastfeeding?

The same drugs used in pregnancy can be taken while breastfeeding, with the following exceptions; aspirin is excreted in breast milk, so should be avoided during breastfeeding because of the theoretical risk of Reye’s syndrome and impaired blood clotting in susceptible infants; metoclopramide is not generally recommended during lactation since small amounts are excreted into breast milk. The triptans almotriptan, eletriptan, frovatriptan, rizatriptan and sumatriptan are licensed for use in breastfeeding provided that you do not breastfeed within 24 hours of the last dose. I would recommend similar advice for naratriptan and zolmitriptan.

Planning a pregnancy

If you are planning a pregnancy, now is the time to discuss with your doctor about any medication you are taking. If you are taking preventative treatments that are not recommended in pregnancy, consider stopping them and/or switching to a safer alternative. For drugs used to treat the symptoms of migraine, try to limit triptans to the first two weeks of the menstrual cycle, when you are unlikely to be pregnant. Now is also the time to get in shape for pregnancy, which will also help migraine – avoid skipping meals, take regular exercise, drink plenty of fluids and start taking a multivitamin supplement for use in pregnancy.

Migraine and Pregnancy Summary Points
  • Migraine may worsen in the first few weeks of pregnancy but usually improves by 16 weeks of pregnancy.
  • Migraine does not harm the baby.
  • Paracetamol/acetaminophen is safe throughout pregnancy and lactation. Aspirin is also safe, but may cause bleeding problems if taken near term.
  • Prochlorperazine has been used for pregnancy-related nausea for many years.
  • Metoclopramide and domperidone are safe, but are probably best avoided during the first trimester.
  • For continuing frequent attacks, which warrant daily preventative treatment, propranolol has best evidence of safety during pregnancy and lactation.
  • If you have taken triptans and then find you are pregnant, do not worry. However, continued use during pregnancy is not recommended.

Rapid advances in medicine may cause information contained here to become outdated, invalid or subject to debate.

  References

1. Maggioni F, Alessi C, Maggino T, Zanchin G. Headache during pregnancy. Cephalalgia1997;17(7):765-9.                                             

2. Sances G, Granella F, Nappi R, et al. Course of migraine during pregnancy and postpartum: a prospective study.Cephalalgia 2003;23(3):197-205.                                                                                                                    

3. Chen T-C, Leviton A. Headache recurrence in pregnant women with migraine. Headache 1994;34:107-110.

4. Granella F, Sances G, Pucci E, Nappi R, Ghiotto N, Nappi G. Migraine with aura and reproductive life events: a case control study. Cephalalgia2000;20:701-7.

5. Wright G, Patel M. Focal migraine and pregnancy. BMJ 1986;293:1557-8.

6. Chancellor A, Wroe S, Cull R. Migraine occurring for the first time in pregnancy. Headache1990;30:224-7.

7. Cupini L, Matteis M, Troisi E, Calabresi P, Bernardi G, Silvestrini M. Sex-hormone-related events in migrainous females. A clinical comparative study between migraine with aura and migraine without aura. Cephalalgia 1995;15:140-4.

8. Wainscott G, Sullivan M, Volans G, Wilkinson M. The outcome of pregnancy in women suffering from migraine. Postgrad Med1978;54:98-102.

9. Rubin P, ed. Prescribing in Pregnancy. 3rd ed. London: BMJ Books, 2000.

10.Slone D, Siskind V, Heinonen O. Aspirin and congenital malformation. Lancet 1976;i:1373-5.

11.Steiner T, MacGregor E, Davies P. British Association for the Study of Headache. Guidelines for all doctors in the diagnosis and management of migraine and tension-type headache. Management Guidelines 2004 available at www.bash.org.uk

12.Loder E. Safety of sumatriptan in pregnancy: a review of the data so far. CNS Drugs  2003;17(1):1-7.

13.Lindout D, Schmidt D. In utero exposure to valproate and neural tube defects. Lancet 1986;ii:1142.

14.Stein G. Headaches in the first post partum week and their relationship to migraine. Headache1981;21:201-5.

written by E. Anne MacGregor, MD

MigraineSurvival is not responsible for the results of your decisions resulting from the use of this information.