Managing Migraine During Pregnancy: Expert Advice About What to Expect

If you're trying to conceive or are pregnant, you likely have a lot of questions about how to most safely manage your migraine effectively. Learn more about your treatment options, what to expect with migraine while you're expecting, and migraine management while breastfeeding.

How Should Someone Treat Migraine While They’re Trying to Conceive?

This is a question that healthcare providers are asked often since migraine affects 25 percent or more of women of childbearing age. It’s important to think about what to expect with migraine in terms of pregnancy, as well as how to change migraine therapies when trying to conceive and during pregnancy itself.

Healthcare providers like to minimize medication use of all kinds during pregnancy. The acute treatments for migraine have short half-lives; triptans, gepants, the ditan lasmiditan (Reyvow), and nonsteroidals are not going to be in the system for very long. That means that if a woman conceives and then takes an acute medication, it's going to be out of her system without significant potential to affect the fetus or the pregnancy within that window of time.

Headache specialists encourage women who are using acute medications to be actively aware of when they might be pregnant. Generally speaking, women are not discouraged from using acute migraine medications during the time they are trying to conceive, but they should reconsider whether they can take the medication once they know they're pregnant.

Concerning preventive therapy, different medications have different levels of risk associated with pregnancy. Some, like divalproex sodium (Depakote), are known to be absolutely contraindicated. Topiramate (Topamax), while not absolutely contraindicated, is not advisable during pregnancy. There is evidence that both divalproex sodium (Depakote) and topiramate (Topamax) can cause fetal abnormalities.

The general rule with other preventive medications is to reduce them as much as possible or stop them while trying to conceive, or as early as possible in the pregnancy.

What Happens to Migraine During Early Pregnancy and the First Trimester?

For some women, migraine worsens within the first trimester of pregnancy. In some cases, women may experience aura for the first time or have a change in aura features. For example, if they had visual aura in the past, they may have sensory or language aura as well. It's a time when migraine clinical features can change.

One important point is that if the headache becomes severe or unresponsive to even conservative treatments, healthcare providers will be concerned about secondary causes. There is a higher chance of secondary headache in the setting of pregnancy due to hypercoagulability (an increased vulnerability to clotting).

What Happens to Migraine During the Second Trimester of Pregnancy?

Generally speaking, that's the time when migraine improves. It becomes less frequent and less severe, likely due to associated hormonal changes. That's the good news.

For an unfortunate minority, severe migraine may persist throughout pregnancy. This can be a difficult situation due to medication limitations, although there are some safe nonmedication and medication options available.

What Happens to Migraine During the Third Trimester of Pregnancy?

Things tend to improve. But the third trimester may be a time when healthcare providers are particularly concerned about the secondary causes of headache. Please report any change in headache characteristics to your healthcare provider. Also, a “black box” warning for the use of nonsteroidal anti-inflammatory drugs after 20 weeks of pregnancy has been recently issued by the U.S. Food and Drug Administration (FDA) because of potential complications that can be caused by these treatments.

When During Pregnancy Should a Woman With a Headache Go to the ER?

If there's an abrupt onset of severe headache, or what is called a thunderclap headache, that is concerning for a secondary cause and requires an emergency evaluation.

Another reason would be if there are signs or symptoms of preeclampsia or eclampsia, high blood pressure which can cause headache. In the setting of pregnancy, if you experience new onset of neurological symptoms (weakness, numbness, or vision loss) other than typical aura symptoms, please seek urgent medical evaluation to look for a secondary cause of headache.

What Are Recommended Prescription Therapies for Pregnant Women With Migraine?

Biobehavioral approaches including biofeedback, cognitive behavioral therapy, mindfulness, and exercise should be maximized as safe, evidence-based treatment options for migraine in pregnancy. However, healthcare providers have to weigh the possibilities that a migraine attack itself is going to have more severe effects than the medication used, especially if a woman has significant nausea and vomiting. There is fairly extensive registry data demonstrating that triptans aren't associated with a risk of adverse consequences for the mother or fetus.

Neuromodulation is also an option during pregnancy. There is no indication that the neuromodulation techniques have adverse consequences on the mother or fetus.

Nerve injections using lidocaine might also be considered during pregnancy. These are safe, well tolerated, and may be effective in the setting of pregnancy for acute relief or scheduled periodically for prevention.

There are some pharmacologic options for migraine prevention that are considered to be safer than others in the setting of pregnancy including magnesium, propranolol, and memantine. However, initiating any medication in the setting of pregnancy requires a benefit versus risk conversation individualized to the patient’s medical care and severity of migraine disease.

What Are Some Home Remedies That a Woman With Migraine Can Use During Pregnancy?

Women who are trying to conceive often stop caffeine and that can be a trigger for worsening of migraine. It may help to reintroduce a small amount of caffeine daily in the morning.

Some of the essential oils, also, may be helpful.

How Does Breastfeeding Affect Migraine?

The good news is that most women get a break from migraine while breastfeeding. If they've had relief from migraine during pregnancy, then they continue to have a break during the period of breastfeeding leading up to weaning. After several months of breastfeeding, migraine typically returns.

Triptans, especially sumatriptan, are safe during breastfeeding. More caution is used with other acute therapies like nonsteroidal anti-inflammatories. Opioids and butalbital are to be avoided with migraine, in general, and particularly during breastfeeding.

There are multiple preventive options that have good safety ratings to be used during lactation, including magnesium, propranolol, and verapamil.

As with pregnancy, breastfeeding may be a time to consider using injection approaches.

Any Final Tips for Pregnancy and Migraine?

Pregnancy is a time when there are tremendous changes in lifestyle and the presence of trigger factors. Pregnancy is associated with the disruption of sleep patterns; it may be associated with different patterns of eating or hydration. These changes can contribute to migraine during pregnancy and postpartum. They also represent potential targets to try to help manage migraine during this time.

Paying attention to sleep, avoiding skipping meals, staying adequately hydrated, keeping a consistent exercise routine, and employing stress management techniques can be important for women — not just during pregnancy but also after pregnancy when a whole new set of stressors and lifestyle changes are introduced.

Most important, remember that the majority of women have improvement of migraine during the second and third trimester, and that there are multiple safe acute and preventive treatment options if necessary.

This article was edited by Angie Glaser and Elizabeth DeStefano, based on an interview with Rebecca Brook NP. Paula K. Dumas also contributed to the content, reviewed by Drs. Starling and Charles.