Migraine in Pregnancy: Considerations for Treatment

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Migraine is very common in women of child-bearing years. Studies have shown that some women with migraine are reluctant to get pregnant due to fears about the pregnancy itself or what effects migraine may have on their developing fetus. Those fears are unfounded as most women with migraine have improvement in migraine disability during pregnancy and the vast majority will have healthy full-term pregnancies. As health care providers, we play a pivotal role in reassuring women with migraine that it is safe to become pregnant and that safe treatment options are available for migraine attacks that may occur during pregnancy and lactation.

Given that complete elimination of any drug is 5 half-lives, a discussion about pregnancy ideally starts at least 6 months prior to attempting pregnancy. Issues to discuss 6 months prior to trying to conceive include:

• Stopping a calcitonin gene-related peptide (CGRP) receptor antagonist monoclonal antibodies (mAB) allowing for complete elimination. The half-lives range from 27-31 days for this category of injectable/IV migraine preventives.
• Identify harmful health habits, set up a plan to optimize health habits and lifestyle prior to pregnancy.
• Review current medications to identify what should be stopped. Medications which should be tapered off and/or stopped include CGRP mABs, antiepileptics including topiramate, ergotamine, and dihydroergotamine, and any other medications deemed potentially unsafe for pregnancy.
• Institute nonpharmacologic treatments such as vitamin B2 and magnesium for prevention; noninvasive stimulators (eg, neuromodulation) for both acute and preventive treatment; biofeedback/cognitive behavioral treatment (CBT); acupuncture; stress-reduction, etc.
• Advise the patient to start taking prenatal vitamins including a sufficient amount of folic acid to prevent a neural tube defect.

Acute Pharmacologic Treatment Options for Migraine during Pregnancy

1. Acetaminophen 325 mg 1-2 as needed; maximum 4000 mg/day
2. Caffeine (recommended maximum intake 200 mg/day)
3. Doxylamine 10 mg/pyridoxine 10 mg for nausea; max 4 tablets/day
4. Diphenhydramine 25-50 mg every 6 hours as needed
5. Metoclopramide 5-10 mg every 8 hours as needed; max 60 mg/day
6. Promethazine 25 mg every 6 hours as needed
7. Prochlorperazine 5-10 mg every 6 hours as needed
8. Sumatriptan and other triptans in moderation
9. Magnesium IV (limited time frame)
10. Diphenhydramine and metoclopramide and fluids IV if severe migraine

Procedure Options for Acute Migraine During Pregnancy

1. Occipital nerve blocks with lidocaine or bupivacaine
2. Sphenopalatine nerve blocks with lidocaine or bupivacaine
3. Trigger point injections with lidocaine or bupivacaine
4. Onabotulinum toxin A (weigh risks vs benefits)

Medications for Acute Migraine to Avoid During Pregnancy:

1. Ergotamine and ergot alkaloids
2. Nonsteroidal anti-inflammatory drugs
3. Oral CGRP receptor antagonists (gepants) (insufficient data)
4. Ditans (insufficient data)
5. Butalbital and narcotics

Preventive Treatment Options for Migraines During Pregnancy

1. Beta blockers
2. Tricyclic antidepressants (try to taper off during 2nd trimester)
3. Memantine
4. Onabotulinum toxin A (weigh risks vs benefits)
5. B2 (riboflavin) and magnesium (max 400 mg per day for each)
6. CBT\biofeedback
7. Physical therapy, massage therapy, acupuncture, meditation, yoga
8. Adequate hydration, healthy diet, exercise, and sleep
9. Noninvasive neuromodulators

Importantly, most women experience improvement with their migraines during pregnancy. The goal is to use the least amount of medication needed at the lowest effective dose to manage migraine during pregnancy. Fortunately, most women with migraine can enjoy pregnancy with minimal aggravation of their migraine attacks.

This is part 1 of a 2-part series on migraine in pregnancy and lactation. Stay tuned for part 2, "Migraine in Pregnancy & Lactation: Considerations for Treatment."