Migraine treatment in pregnancy

First-Line Treatment:

• Acetaminophen (Paracetamol):
  • Safe in pregnancy (FDA category B).
  • Dose: 500–1000 mg every 4–6 hours (max 4 g/day).
  • Rationale: Well-studied, minimal teratogenic risk, effective for mild-to-moderate pain.

• Second-Line Treatment:
• NSAIDs (e.g., Ibuprofen):
  • Avoid in first and third trimesters (FDA category C/D).
  • Use cautiously in second trimester if necessary (short-term, lowest effective dose).
  • Rationale: Risk of fetal renal dysfunction, premature closure of ductus arteriosus, and increased bleeding risk.

• Avoid:
• Triptans (e.g., Sumatriptan):
  • Limited data, potential vasoconstrictive effects (FDA category C).
  • Avoid unless no alternatives; if used, prefer sumatriptan (lowest risk among triptans).
  • Rationale: Theoretical risk of fetal vascular compromise; no strong evidence of harm, but caution advised.

• Preventive Therapy (if necessary):
• Magnesium (240–400 mg/day):
  • Safe in pregnancy (FDA category A).
  • Rationale: May reduce migraine frequency, no known teratogenic effects.
• Lifestyle Modifications:
  • Hydration, regular meals, stress reduction, sleep hygiene.
  • Rationale: Non-pharmacologic, low-risk, may reduce triggers.

• Avoid:
• Beta-blockers (e.g., Propranolol):
  • Avoid unless essential (FDA category C).
  • Rationale: Potential fetal bradycardia, growth restriction.
• Valproate, Topiramate, and Other Antiepileptics:
  • Contraindicated (high teratogenic risk, e.g., neural tube defects).
  • Rationale: Strong evidence of fetal harm (e.g., valproate linked to 10–20% risk of major congenital anomalies).

• Special Considerations:
• Migraine with Aura:
  • Increased risk of stroke (relative risk ~2–4x in non-pregnant women; data in pregnancy limited).
  • Rationale: Consider low-dose aspirin (75–100 mg/day) if no contraindications (e.g., preeclampsia risk).
• Emergency Treatment (e.g., Status Migrainosus):
  • IV fluids, IV metoclopramide (FDA category B), or IV acetaminophen.
  • Rationale: Avoid opioids (risk of neonatal withdrawal, respiratory depression).

Key References:

• ACOG (2017): Recommends acetaminophen as first-line for acute migraine.

• EHEDG (2016): Supports magnesium for prevention in pregnancy.

• Bushnell et al. (2009): Highlights stroke risk in migraine with aura.