Migraine in pregnancy

Migraine commonly affects women in their childbearing years, so it is not surprising that many women with migraine ultimately become pregnant. A cooperative relationship between the migraine sufferer and her physicians is essential in minimizing the impact of migraine during pregnancy.

The good news is that the majority of migraine sufferers will note significant improvement in their headaches during the second and third trimesters. Well-done studies have repeatedly shown that while headaches may worsen somewhat in the first trimester, two-thirds of women suffering from migraine without aura will note significant improvement in their headache in the last two trimesters, especially if their migraines correlated closely with the onset of menstruation, occurred around the time of their menstrual periods, or with the onset of birth control pill use. Migraine headaches usually resume their pre-pregnancy pattern in the postpartum period. Tension-type headaches are not generally thought to be related to hormones and are largely unaffected by pregnancy.

The majority of fetal development occurs in the first trimester. Thus, though non-drug approaches are emphasized throughout the pregnancy, they are especially important in the first trimester. Fortunately, it should be noted that there is no evidence of increased incidence of birth defects in the offspring of patients with migraine.

It is important to stop all over-the-counter medications except prenatal vitamins as soon as you know that you are pregnant. Most vitamin supplements and herbal preparations have not been extensively studied in pregnancy. You must report all medications used, including over-the-counter medications and herbal products, to your headache physician and OB at every visit during the pregnancy.

Your doctor will maximize non-drug therapies throughout your pregnancy but especially in the first trimester. Below are specific suggestions to prevent or treat headaches:

  • Rest - This cannot be overemphasized. A temporary decrease in work responsibilities, especially in the first trimester, is preferable to using medications.
  • Stress - A conscious effort to reduce stress is important. Sharing responsibilities, decreasing commitments, and obtaining adequate rest and exercise is strongly encouraged.
  • Sleeping/eating patterns - It is very important to regulate sleeping and eating patterns to minimize headache. Skipping meals is strongly discouraged as this often triggers headaches.
  • Caffeine - Caffeine should be eliminated or reduced as much as possible, especially in the first trimester.
  • Trigger identification - This also is important. Try to identify specific triggers that consistently bring on your headaches (food, MSG, alcohol, bright lights, lack of sleep, certain odors, etc.) and strictly avoid them if at all possible.
  • Nausea - Treat nausea early and aggressively. Avoid strong odors. Use Seabands, and/or finger acupressure over acupressure point P6 (information sheet available on request).
  • Hydration - Avoid becoming dehydrated. Use clear liquids, soups, Popsicles, etc., and a bland diet such as rice, bananas, crackers, etc. If dehydration worsens, we can give you IV fluids in the office.
  • Relaxation techniques - Methods such as biofeedback, guided imagery, relaxation exercises, etc., can be very helpful (information sheets available on request).
  • Massage therapy - Massage therapy and physical therapy can be very helpful in alleviating certain types of headache pain.
  • Acupuncture - Please note that acupuncture is generally not recommended in pregnancy. Ice packs - These should be used early and often in migraine attacks as an effective non-drug way to improve pain.
  • Stimulus control - During a migraine, decrease stimulation as much as possible. Go to a quiet, dark room if at all possible. You likely will need someone to help watch the kids, take over responsibilities, etc. Plan ahead.

Medications

If medications are to be used, certain principles are to be followed:

  • All medications used, including over-the-counter medication, should be reported to the OB and headache physicians.
  • Non-drug methods should always be tried first.
  • If meds are used, their use should be delayed until the second and third trimesters, if at all possible.
  • The lowest dose of medication for the shortest period of time is recommended.
  • The medications used will be those that pose the least threat to the mother and fetus.
  • Information will be made available to the patient and treating OB physicians.
  • The first line agent is acetaminophen. One or two regular-strength tablets can be used (or a rectal suppository if nausea is present).
  • If this is not helpful, the second line medications generally are simple narcotics or pain relief medications such as meperidine or oxycodone. These can be constipating and should be used sparingly. They are rarely used to treat migraines in non-pregnant patients because better alternatives are available for the non-pregnant patient. Their safety in pregnant patients is well established.

Summary

  • Migraines can occur in women who become pregnant.
  • They usually get better during the second and third trimesters.
  • All over-the-counter medications (except prenatal vitamins) and herbal preparations should be stopped during pregnancy.
  • Non-drug treatments must be maximized.
  • If medications are used, the initial agent of choice is acetaminophen orally or rectally.
  • Your doctor will be available to help you throughout your pregnancy with your headaches.

Resources

  • For a list of articles on women's headache issues, click here.