TREATMENT OF MIGRAINE IN PREGNANCY

Migraine is common in women of reproductive age and may occur in pregnancy. It has been estimated that in up to 80% of women who experience migraines, both the frequency and severity of attacks improve during the second and third trimesters of pregnancy, thus routine prophylaxis with therapies such as topiramate or propranolol is not recommended during pregnancy. However, in some cases migraine may fail to improve, or worsen. In some women migraine presents for the first time during pregnancy.

Migraine itself does not appear to increase the risk of miscarriage, congenital malformation or other pregnancy complications. However, if migraines are frequent or severe and left untreated, subsequent maternal effects such as dehydration, inadequate nutrition and stress may have an adverse effect on the fetus.

If appropriate, non-pharmacological measures, including identification and avoidance of trigger factors, should be tried before drug therapy is considered. Medication may be required for headaches that are severe and associated with nausea and vomiting. Adequate fluid replacement is needed for dehydration.

Paracetamol is considered the most appropriate first-line pharmacological therapy for acute attacks of migraine. Depending on the stage of pregnancy, NSAIDs may offer alternative therapeutic options, and sumatriptan may also be considered, although there is less evidence of safety in pregnancy for these agents than for paracetamol. Use of prophylactic therapies may be justifiable for some women and should be decided on an individual basis depending on severity and frequency of attacks, the patient’s prior responsiveness to treatment, stage of pregnancy, and risk of teratogenicity. Efficacy of prophylaxis and need for ongoing use should be reviewed throughout pregnancy.

Treatment of migraine at any stage in pregnancy with the medicines listed above would not usually be regarded as medical grounds for termination of pregnancy. Use of NSAIDS beyond the second trimester carries a risk of premature closure of the ductus arteriosus and should therefore be avoided. Should exposure to an NSAID after the second trimester occur, referral for fetal assessment is advised as additional monitoring may be indicated. Other risk factors which independently increase the risk of adverse pregnancy outcome may also be present in individual cases. Clinicians are reminded of the importance of consideration of such factors when performing case-specific risk assessments.

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