How To Treat Migraine During Pregnancy

Migraine occurs more frequently in women compared to men and peaks during a woman’s reproductive years.¹ Previous studies suggest that about 21-28% of women of reproductive age experience migraine annually, and up to 80% of these women will continue to have migraine during some phase of pregnancy.¹ Approximately 50% of women with migraine report improvement in migraine symptoms by the end of the first trimester, and these reductions in frequency and severity may rise to over 80% in the second and third trimesters.² However, other data suggest that over 60% of these women may not experience headache improvement during pregnancy, with women who have migraine with aura being less likely to improve.³ Additionally, some women may experience migraine attacks for the first time during pregnancy, which is more likely to be associated with aura.⁴

Challenges and Limitations

Unfortunately, there are no large controlled clinical trials conducted in this population to evaluate the safety and efficacy of treatments during pregnancy, partly due to ethical concerns and long-term safety issues and also because of the paucity of standardized treatment guidelines. This presents a significant limitation, as many pregnant patients continue to treat migraine attacks during pregnancy. 

In May 2022, the American College of Obstetricians and Gynecologists (ACOG) released clinical practice guidelines for the treatment of headaches during pregnancy and postpartum.⁵ This represents an important first step in improving and standardizing migraine care for this unique patient population. Due to the limited high-quality data, a shared decision-making model is recommended.⁵ Green indicates recommended options, yellow suggests treatments that can be used with caution, and red signifies those that should be avoided.⁵

Table adapted from ACOG.⁵

Acute and Preventive Therapies

The following flowchart summarizes an approach to managing migraine in pregnant women, taking into account the American Headache Society’s published guidelines on the safety and efficacy of acute and preventive therapies during pregnancy.⁶

Chart courtesy of Practical Neurology.

Risk vs Benefit

It is crucial that patients are thoroughly informed about the potential risks of treatment to both mother and fetus. A current or past diagnosis of migraine is linked to several maternal complications during pregnancy, including preeclampsia and other hypertensive disorders, dyslipidemia, acute myocardial infarction and heart disease and stroke.^7-12 Migraine may also impact fetal development, with potential links to low birth weight, delivery by cesarean section and preterm birth.^7,10 Beyond physical health, migraine can contribute to increased presenteeism and absenteeism in the workplace. As with any treatment during pregnancy, careful consideration of the potential risks and benefits for both mother and fetus is important.

Preconception Counseling

Given that many pregnancies are unplanned, it’s important to routinely ask patients about their reproductive plans. For those taking medications with teratogenic potential (e.g., certain antiepileptic drugs), ensure that effective contraception is in place. For patients seeking preconception counseling, it can be reassuring to share that migraine often improves during pregnancy and that safe and effective treatment options are available to manage symptoms.

Introduce behavioral strategies, lifestyle modifications, and acute treatments with favorable safety profiles prior to conception—such as select medications, devices, or nerve blocks. When discussing preventive therapies, note that data on the safety of CGRP monoclonal antibodies and gepants during pregnancy and lactation are limited. Current guidance suggests discontinuing CGRP monoclonal antibodies 4–6 months before conception and stopping gepants 5–7 days beforehand.¹

Optimize Lifestyle Modifications

Optimizing lifestyle modifications before pregnancy is a key part of managing migraine and can help reduce the frequency and severity of attacks. 

Here are some strategies to consider:¹³

• Sleep hygiene: Encourage patients to establish a regular sleep schedule, aiming for 7 to 9 hours of quality sleep each night. Advise them to avoid excessive screen time before bed and to create a calm, dark, and quiet sleep environment.
• Dietary adjustments: Help patients identify potential food triggers (e.g., caffeine, processed foods). Recommend a balanced, nutrient-rich diet and encourage regular meals to avoid fasting, which can trigger migraine attacks.
• Hydration: Ensure the patient is staying well-hydrated by drinking enough water throughout the day. 
• Stress management: Recommend stress-reduction techniques, such as mindfulness, yoga, deep breathing exercises, or meditation. 
• Exercise: Promote regular, moderate exercise, such as walking, swimming, or cycling. Regular physical activity can improve circulation, reduce stress, and help maintain a healthy weight, all of which can be beneficial for migraine prevention.
• Mind-body therapies: Encourage the patient to consider therapies like biofeedback, acupuncture (with a provider skilled in treating pregnancy), or cognitive behavioral therapy (CBT).

By making these lifestyle changes before pregnancy, women can potentially decrease the frequency of migraine attacks and enhance their overall well-being, establishing a stronger foundation for pregnancy and migraine management during this period.

Screen for Secondary Headaches

Migraine is common during pregnancy; however, clinicians should be mindful of the potential for more serious secondary headaches caused by the systemic and hypercoagulable changes that occur during this time. 

Key red flags to screen for include new-onset or refractory headaches—even in patients with a known history of migraine—as well as the development of hypertension.¹⁴ Any change in headache pattern, severity, or response to treatment warrants a thorough evaluation to rule out serious conditions such as preeclampsia, stroke, or venous thromboembolism.

Red flags for secondary causes of headache in pregnancy may be remembered using the mnemonic PREGNANT HA:¹⁵

• Proteinuria
• Rapid onset
• Elevated blood pressure or temperature
• Gestational age in the third trimester
• Neurological signs or symptoms
• Altered level of consciousness
• No headache history or known history of a secondary headache disorder
• Thrombocytopenia or thrombocytosis
• High liver function tests or CRP
• Agonizingly severe pain

Evaluation and management of secondary headache courtesy of ACOG.⁵

Neuromodulation Devices

Neuromodulation devices are considered for off-label use in pregnancy. However, expert consensus suggests devices are relatively safe during pregnancy.^14,16,17 

Image from Migraine Explainer Videos.

Pregnancy Registries

If the benefits outweigh the risks and the patient and provider decide to continue the current migraine medication during pregnancy, consider advising the patient to join the appropriate pregnancy registry associated with their medication, if one exists. These registries monitor outcomes during and after pregnancy, assess fetal health, and contribute to the limited data on medication safety in pregnancy, providing valuable insights for both clinical care and future research.

Summary

Managing migraine attacks during pregnancy requires a personalized, shared decision-making approach, taking into account factors such as the pregnancy trimester, the level of evidence, disability, risk assessment, and any comorbidities. Emphasis is placed on non-pharmacologic therapies and lifestyle modifications. An open discussion about the risks and uncertainties of additional options is crucial for patients who do not respond to conservative treatments. 

Currently, the most robust safety data for acute treatments includes acetaminophen, metoclopramide with or without diphenhydramine, peripheral nerve blocks with lidocaine or ropivacaine, and caffeine (less than 200 mg).¹ NSAIDs are recommended only during the second trimester (12-20 weeks gestation).¹ Second-line treatment options include triptans, short-acting prednisone, promethazine, and prochlorperazine.¹ 

For prevention, first-line or preferred options include calcium channel blockers like verapamil, amlodipine, and nifedipine due to their relative safety during pregnancy.⁵ Additional medications such as beta blockers (ex., propranolol), amitriptyline, cyproheptadine may be initiated or continued if the potential benefits outweigh the risks.^1,5 OnabotulinumtoxinA for chronic migraine may also be considered under the same risk-benefit framework.^1,5 Currently, there is insufficient data to support the use of newer treatments, such as CGRP inhibitors and ditans, during pregnancy.^1,5 Providers may recommend certain neuromodulation devices off-label as an acute and/or preventive treatment.^14,16,17

Ongoing research findings and evolving clinical guidelines will play a critical role in helping clinicians navigate these complexities and enhance care for pregnant women with migraine.

References

1. Burch R. Epidemiology and Treatment of Menstrual Migraine and Migraine During Pregnancy and Lactation: A Narrative Review. Headache. 2020 Jan;60(1):200-216. doi: 10.1111/head.13665. Epub 2019 Oct 3. PMID: 31579938.
   https://headachejournal.onlinelibrary.wiley.com/doi/full/10.1111/head.13665
2. Sances G, Granella F, Nappi RE, et al. Course of migraine during pregnancy and postpartum: a prospective study. Cephalalgia. 2003; 23: 197-205. https://pubmed.ncbi.nlm.nih.gov/12662187/
3. Verhaak A, Bakaysa S, Johnson A, Veronesi M, Williamson A, Grosberg B. Migraine treatment in pregnancy: A survey of comfort and treatment practices of women’s healthcare providers. Headache. 2023 Feb;63(2):211-221. doi: 10.1111/head.14436. Epub 2023 Jan 25. PMID: 36695287.
   https://pubmed.ncbi.nlm.nih.gov/36695287/
4. Cupini LM, 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: 140-144.
   https://pubmed.ncbi.nlm.nih.gov/7641250/
5. American College of Obstetricians and Gynecologists. Clinical practice guidelines: headaches in pregnancy and postpartum. Obstet Gynecol. 2022; 139: 944-971.
   https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2022/05/headaches-in-pregnancy-and-postpartum
6. https://practicalneurology.com/articles/2023-may-june/management-of-headache-in-pregnant-women
7. Chen HM, Chen SF, Chen YH, Lin HC. Increased risk of adverse pregnancy outcomes for women with migraines: a nationwide population-based study. Cephalalgia. 2010 Apr;30(4):433-8. doi: 10.1111/j.1468-2982.2009.01935.x. Epub 2010 Feb 15. PMID: 19614685.
   https://pubmed.ncbi.nlm.nih.gov/19614685/
8. Adeney KL, Williams MA, Miller RS, Frederick IO, Sorensen TK, Luthy DA. Risk of preeclampsia in relation to maternal history of migraine headaches. J Matern Fetal Neonatal Med. 2005 Sep;18(3):167-72. doi: 10.1080/14767050500260566. PMID: 16272039.
   https://pubmed.ncbi.nlm.nih.gov/16272039/
9. Facchinetti F, Allais G, Nappi RE, D’Amico R, Marozio L, Bertozzi L, Ornati A, Benedetto C. Migraine is a risk factor for hypertensive disorders in pregnancy: a prospective cohort study. Cephalalgia. 2009 Mar;29(3):286-92. doi: 10.1111/j.1468-2982.2008.01704.x. PMID: 19220309.
   https://pubmed.ncbi.nlm.nih.gov/19220309/
10. Skajaa N, Szépligeti SK, Xue F, Sørensen HT, Ehrenstein V, Eisele O, Adelborg K. Pregnancy, Birth, Neonatal, and Postnatal Neurological Outcomes After Pregnancy With Migraine. Headache. 2019 Jun;59(6):869-879. doi: 10.1111/head.13536. Epub 2019 May 8. PMID: 31069791.
    https://pubmed.ncbi.nlm.nih.gov/31069791/
11. Gelaye B, Larrabure-Torrealva GT, Qiu C, Luque-Fernandez MA, Peterlin BL, Sanchez SE, Williams MA. Fasting lipid and lipoproteins concentrations in pregnant women with a history of migraine. Headache. 2015 May;55(5):646-57. doi: 10.1111/head.12571. Epub 2015 Apr 22. PMID: 25904286; PMCID: PMC4439363.
    https://pubmed.ncbi.nlm.nih.gov/25904286/
12. Wabnitz A, Bushnell C. Migraine, cardiovascular disease, and stroke during pregnancy: systematic review of the literature. Cephalalgia. 2015 Feb;35(2):132-9. doi: 10.1177/0333102414554113. Epub 2014 Oct 10. PMID: 25304764.
    https://pubmed.ncbi.nlm.nih.gov/25304764/
13. https://effectivehealthcare.ahrq.gov/products/headaches-pregnancy/protocol#:~:text=Therapies%20that%20are%20commonly%20used,antihistamines%2C%20caffeine%2C%20and%20magnesium
14. Parikh SK, Delbono MV, Silberstein SD. Managing migraine in pregnancy and breastfeeding. Prog Brain Res. 2020;255:275-309. doi: 10.1016/bs.pbr.2020.07.011. Epub 2020 Aug 18. PMID: 33008509.
    https://pubmed.ncbi.nlm.nih.gov/33008509/
15. Sandoe CH, Lay C. Secondary Headaches During Pregnancy: When to Worry. Curr Neurol Neurosci Rep. 2019 Apr 22;19(6):27. doi: 10.1007/s11910-019-0944-9. PMID: 31011857.
    https://pubmed.ncbi.nlm.nih.gov/31011857/
16. Holdridge A, Donnelly M, Kuruvilla DE. Integrative, Interventional, and Non-invasive Approaches for the Treatment for Migraine During Pregnancy. Curr Pain Headache Rep. 2022 Apr;26(4):323-330. doi: 10.1007/s11916-022-01028-8. Epub 2022 Apr 1. PMID: 35362816.
    https://pubmed.ncbi.nlm.nih.gov/35362816/
17. Peretz A, Stark-Inbar A, Harris D, Tamir S, Shmuely S, Ironi A, Halpern A, Chuang L, Riggins N. Safety of remote electrical neuromodulation for acute migraine treatment in pregnant women: A retrospective controlled survey-study. Headache. 2023 Jul-Aug;63(7):968-970. doi: 10.1111/head.14586. Epub 2023 Jun 19. PMID: 37335242.
    https://pubmed.ncbi.nlm.nih.gov/37335242/

Author

Andrea Murphy is a board-certified adult primary nurse practitioner with extensive experience in headache diagnosis, treatment and management. She has been a practicing nurse since 2009 and went on to help establish the first headache medicine program at Hartford HealthCare (HHC) in 2015. She continues to practice as a headache specialist in private practice in South Windsor, CT.

From her diverse background in internal medicine, she applies a unique patient centered approach where each person with headache is seen as an individual and offered a tailored treatment plan. Andrea has a deep commitment to medical education and works to educate clinicians and patients in the approach to headache. Andrea is most passionate about migraine advocacy and empowering others to improve their own health and well-being. 

Areas of clinical interest include holistic non-pharmacological treatments of headache, migraine during pregnancy, chronic migraine, and menstrual related migraine.