A 25-Year-Old Pregnant Woman With Worsening Headaches

Nancy Hammond, MD


June 07, 2018

Treatment of headache during pregnancy is complicated due to possible teratogenic effects of medications. If a cause of headache is found, treatment should focus on the underlying condition. If a primary headache is diagnosed, nonpharmacologic measures should be the first step. Women should be encouraged to keep a headache journal to identify possible triggers. Common migraine triggers include stress, irregular sleep, erratic meals, dehydration, and either caffeine overuse or withdrawal. Certain foods can also trigger migraine, and a headache journal can be very helpful in determining specific triggers for an individual patient. Relaxation techniques, biofeedback, and acupuncture may all be helpful in reducing headache frequency. Preventive therapy for migraine should be considered if headaches are occurring once a week or more or if headaches are leading to missed work or other disability.

Acute treatments for migraine are challenging in pregnant women. Acetaminophen is commonly thought to be safe during pregnancy and can be used for mild-to-moderate headaches. Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally felt to be safe to take in the first and second trimester and are probably more effective for acute migraine.[5] Triptans, such as sumatriptan, are serotonin agonists and are highly effective for migraine. Animal studies have shown teratogenic risk, but pregnancy registries for sumatriptan, naratriptan, and rizatriptan have not shown an increased teratogenic risk.[6] Triptans are a reasonable option if acetaminophen or NSAIDs do not provide adequate headache relief. Antiemetic medications should be considered as an adjunctive treatment for migraine during pregnancy. Metoclopramide and prochlorperazine have not been shown to contribute to fetal malformations.[7] They are effective for both relief of migraine pain and nausea.[8]

Preventive medications should be considered when migraines occur once a week or more or if the woman has significant disability due to migraine attacks. The most common migraine preventives include blood pressure medications, antiepileptic medications, and tricyclic antidepressants. When considering a preventive medication, the lowest effective dose should be used in order to minimize any possible teratogenic effects.

Propranolol is a beta blocker used for migraine prevention. Human studies have not shown any teratogenic effects; however, propranolol should be discontinued if possible in the third trimester to reduce the risk for fetal bradycardia. Amitriptyline is a tricyclic antidepressant that is widely used for migraine prevention. It is generally believed to be safe to take at low doses during pregnancy. Topiramate is an antiepileptic medication commonly used for migraine prevention; however, topiramate should not be used during pregnancy or in a woman desiring pregnancy because of teratogenic risk. Supplemental oral magnesium, riboflavin, and Co-Q10 may have a role in migraine prevention during pregnancy.


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