Women who have a tendency for migraine headaches may discover that they experience fewer migraines during pregnancy, however some women may encounter the same amount or even more. Some women even experience their first attacks during this time.

Migraine often recurs after the baby is born or can begin for the first time. Although studies have not absolutely established the safety of any medication during pregnancy, some are believed to be relatively safe (1).

Non-drug treatments can help

Since migraine often improves after the first three months, many women can manage their headaches by using non-drug treatments, such as icepacks, massage, and biofeedback. But for some women, headaches will be severe, sometimes associated with nausea, vomiting and possible dehydration. In this case, the risk to the foetus may be greater than the potential risk of the medications (2, 3).

Medications to treat headaches when they occur

Symptomatic medications reduce the severity and duration of headache symptoms, and are used to treat an acute attack. They should be used when non-drug treatments (eg icepacks, rest, massage, etc) are ineffective. The non-steroidal anti-inflammatories (NSAIDs) (eg ibuprofen, naproxen), acetaminophen (Tylenol), codeine, or other opioids can be used during pregnancy (4).

Aspirin taken at low doses occasionally is not a significant risk to the foetus although large doses may be associated with bleeding in the mother and foetus. It is recommended that aspirin be avoided unless there is a definite need for it (other than headache).

In general, NSAIDs can be safely taken during the first three months of pregnancy, however they should only be used on a limited basis during later pregnancy.

Barbituate and benzodiazepine use should be limited.

Ergotamine, dihydroergotamine (DHE) and triptans should be avoided (5, 3). However, a recent study found that sumatriptan did not appear to pose an increased risk and that no pattern of defects had been observed. But it is best advised to discuss any medication use with your doctor.

Medications for associated migraine symptoms

Metoclopramide, which decreased nausea and enhances the absorption of medication, is a useful drug in treating migraine. Mild nausea can be treated with phosphorylated carbohydrate solution (emetrol) or doxylamine succinate and vitamin B6 (4, 6). Trimethobenzamide, chlorpromazine, prochlorperazine can be taken orally, as an injection, and suppository, and can all be used safely.

Corticosteroids can be used occasionally. Domperidone is an anti-nausea medication used outside the US. In the UK it is not advised during pregnancy because of its effects on the embryo in animal tests (7).

For severe migraine attacks, IV fluids for hydration and then prochlorperazine 10 mg IV to control nausea and head pain can be used. IV opioids or IV corticosteroids can be used as a supplement.

Before you take medication, try and relieve your headache with one or more of the following interventions:

• If you have a sinus headache, apply a warm compress around your eyes and nose.
• For tension headache or migraine, apply a cold compress or ice pack at the base of your neck.
• For migraine headache, try to avoid the triggers that can bring on an attack (link to triggers).
• Maintain your blood sugar by eating smaller more frequent meals.
• Massage your shoulders and neck to try and relieve the pain. Massaging peppermint oil into your temples is also effective for some sufferers.
• Rest in a dark room, and use relaxation techniques such as deep breathing, if they have proven to be effective.

Preventive treatment

If severe migraine occurs frequently and is associated with nausea and vomiting then the use of daily preventive (prophylactic) medications may be justified. This treatment option, designed to reduce the frequency and severity of attacks should be used as a last resort.

Preventive medications should be considered only if a patient experiences at least three or four prolonged, severe attacks per month that are particularly disabling and/or do not respond to symptomatic therapy and may result in dehydration and endanger the fetus (3, 8).

Beta-adrenergic blockers such as propranolol have been used in these cases with serious associated adverse effects so should be avoided (4, 6, 8).

What to do if you have inadvertently taken medication during pregnancy

Let your doctor know what you took, the dose, at what stage during pregnancy, and the duration of the exposure (ie how many days/weeks). Based on this information, your past and present state of health, and your family medical history, your doctor will try and establish whether the drug is likely to pose a risk to you and/or your baby.

If the drug is known to cause birth defects, or the risk is unknown, your obstetrician should check the status of the fetus using ultrasound. However, foetal ultrasound cannot detect minor deformities or predict or diagnose cognitive developmental before birth.

Final word

Before taking any medication at all, including herbal or alternative therapies, talk to your doctor about the potential risks to you and your baby. If you have taken medication while pregnant, discuss the risks with your doctor.

References:

1. Silberstein SD. Headaches in pregnancy. Neurol Clin 2005;22:727-756. 2. Raskin NH. Migraine treatment. In: Raskin NH (ed) Headache, 2nd Edn. Churchill-Livingstone, New York, 1988. 3. Silberstein SD. Appropriate use of abortive medication in headache treatment. Pain Manag 1991;4:22-28. 4. Koren G, et al. Drugs in pregnancy. N Engl J Med 1998;338:1128-1137. 5. Pitkin RM. Drug treatment of the pregnant woman: the state of the art. In: Proceedings from the Food and Drug Administration Conference on Regulated Products and Pregnant Women, Virginia, November 1995. 6. Silberstein SD. Migraine and pregnancy. Neurol Clin 1997;15:209-231. 7. MacGregor A. Treatemnt of migraine during pregnancy. IHS News in Headache 1994;4:3-9. 8. Silberstein SD. Headaches, pregnancy and lactation. In: Yankowitz J, Niebyl JR (eds). Drug therapy in pregnancy, 3rd edn. Lippincott Williams and Wilkins, Philadelphia, 2001, pp. 231-246.

Sources:

Silberstein SD. Headaches in pregnancy. J Headache Pain 2005;6:172-174.

American Pregnancy Association – Pregnancy and Headaches

From the World Headache Alliance website: www.w-h-a.org