Migraine in pregnancy

Pregnancy can affect migraine – and the range of treatments available to you

What will happen to my migraine when I’m pregnant?

Some people find they are more affected by migraine during pregnancy; some find migraine gets better during pregnancy. To some extent, which camp you fall into will be determined by the type of migraine attacks you suffer.

Although it’s common for migraine to worsen in the first 16 week, results from studies suggest that up to 80 per cent of women who experience migraine attacks without aura experience improvements when they are pregnant, particularly during the second and third trimesters.

Since migraine without aura is often associated with falling levels of a hormone called oestrogen, the reason for this improvement could be linked with the more stable levels of oestrogen during pregnancy.

However, there are other physical and emotional changes that take place during pregnancy which could also account for improvements, including increased production of natural painkillers known as endorphins, muscle relaxation, and changes in the body’s sugar balance.

But that’s not the whole story. In contrast to migraine without aura, attacks of migraine with aura follow a very different pattern during pregnancy, with attacks more likely to continue throughout the pregnancy. For some, aura can develop for the first time.

I’m pregnant. Is migraine going to harm my baby?

There is no evidence that migraine, either with or without aura, can increase the risks of miscarriage, stillbirth or congenital abnormalities.

What can I take for migraine attacks when I’m pregnant?

Drugs tend to have the biggest effects on the developing baby during the first month of pregnancy, often before a woman even knows she is pregnant.

When pregnant, you should take as few drugs as possible, at the lowest effective dose, and only as instructed by your doctor.

Drugs taken by women who don’t know they’re pregnant rarely cause harm to the baby. But it’s important to make the distinction between that reassurance and knowingly continuing with drug treatment once you’re aware.

For most medications, evidence of safety in pregnancy and while breastfeeding is circumstantial, since few drugs have been specifically tested in these circumstances.

So, with limited information, drugs are only recommended if the potential benefits to the woman and baby outweigh the potential risks.

Non-drug treatment for migraine during pregnancy

Many pregnant women prefer to avoid drug treatments altogether during pregnancy, particularly once they are aware that migraine is likely to improve with time.

Early pregnancy symptoms, such as sickness, particularly if severe, can reduce food and fluid intake resulting in low blood sugar and dehydration, which can make migraine worse.

Simple advice to eat small, frequent carbohydrate snacks and drink plenty of fluids may help both problems.

Adequate rest is necessary to counter overtiredness, particularly in the first and last trimesters.

Other safe preventative measures that can be tried include biofeedback, yoga, massage, and relaxation techniques. The benefits of these methods can last much longer than the pregnancy!

Drugs to treat the symptoms of migraine

Some painkillers are considered safe to use at different stages during pregnancy. However, always check with your doctor before use, particularly if you are getting headaches more often than a couple of days a week.

• Paracetamol is the drug of choice in pregnancy, having been used extensively without apparent harm to the developing baby.
• Aspirin has been taken by many pregnant women in the first and second terms of pregnancy. However, it should be avoided near the expected time of delivery since it may be lead to side effects, including increased bleeding.
• Codeine is not generally recommended for the management of migraine in the UK, although occasional use in doses found in combined analgesics is unlikely to cause harm.
• Ibuprofen can be taken during the first and second trimesters in doses not exceeding 600mg daily. Avoid frequent use or higher doses after 30 weeks.
• Anti-sickness drugs buclizine, chlorpromazine, domperidone, metoclopramide and prochlorperazine have all been used widely in pregnancy without apparent harm.

As well as standard over-the-counter medications, triptans can also be considered, and studies looking at the safety of sumatriptan during pregnancy have been reassuring. However, don’t continue triptans during pregnancy unless recommended and supervised by a doctor.

Ergotamine should not be used during pregnancy as it can increase the risk of miscarriage.

Drugs to prevent migraine

If your doctor decides daily medication is necessary to prevent migraine attacks during pregnancy, the lowest effective dose of propranolol is generally the first choice. Low dose amitriptyline is a safe alternative.

There are no reports of adverse outcomes from pizotifen used during pregnancy or when breastfeeding, although it isn’t used as often as the drugs above.

Other preventative options include low doses of amitriptyline or nortriptyline, which are considered safe in pregnancy.

A greater occipital nerve (GON) block is another safe method to be considered when migraine deteriorates and become frequent in pregnancy or when breastfeeding. You can find out more about GON blocks by reading our factsheet.

Sodium valproate should not be taken during pregnancy as there is a high risk of it causing foetal abnormalities. Women prescribed sodium valproate for migraine must use effective contraception.

Topiramate should be avoided if you are pregnant, breastfeeding or may become pregnant.

I am pregnant and getting blind spots with my migraine – should I see my doctor?

It is not uncommon for a woman to have her first attack of migraine with aura during pregnancy. The symptoms of aura are typically bright, visual zig-zags, growing in size from a small bright spot and moving across your vision over about 20 to 30 minutes before disappearing. You may also have a dark or blurred spot in the centre of your vision.

A sensation of ‘pins and needles’ moving up the arm into the mouth may accompany this.

If you experience these typical symptoms and your doctor confirms that this is related to migraine, there is no need to be concerned and no tests are necessary.

However, if the symptoms are not typical of migraine aura, it’s important to exclude other possible causes, such as blood clotting disorders or high blood pressure, which may occasionally produce symptoms similar to migraine.

What will migraine be like after I have the baby?

If migraine symptoms have improved, this will usually continue until periods return. However, a bad attack of migraine can occur within a couple of days of delivery. This may be because of the sudden drop in oestrogen that occurs. Exhaustion, dehydration and low blood sugar are other possible causes.

What drugs can I take for migraine attacks when I’m breastfeeding?

The same drugs used in pregnancy, listed above, can also be taken while breastfeeding, with the following exceptions:

• Aspirin should be avoided, as it finds its way into breast milk. It carries with it the theoretical risk of Reye’s syndrome, with impaired blood clotting in susceptible babies.
• Metoclopramide is not generally recommended during breastfeeding since small amounts will be present in the breast milk.
• The licensing for sumatriptan indicates that a 12-hour delay between taking the drug and breastfeeding is necessary. However, many doctors consider it safe since only very small amounts would be present in breast milk. Speak to your GP or headache specialist.
• Almotriptan, eletriptan, frovatriptan, and rizatriptan are licensed for use while breastfeeding providing that you do not breastfeed within 24 hours of the last dose.  Similar advice is generally given for naratriptan and zolmitriptan.

Planning a pregnancy

If you are planning a pregnancy, now is the time to discuss with your doctor any medication you are taking.

If you are taking migraine preventative treatments that are not recommended in pregnancy, you need to consider stopping them and switching to a safer alternative.

For drugs used to treat the symptoms of migraine, try to limit triptans to the first two weeks of the menstrual cycle, when you are unlikely to be pregnant.

Now is also the time to get in shape for pregnancy, which will also help migraine. Avoid skipping meals, take regular exercise, drink plenty of fluids and start taking a multivitamin supplement for use in pregnancy.

Key points

• Migraine may worsen in the first few weeks of pregnancy but usually improves by 16 weeks
• Paracetamol is considered safe throughout pregnancy. Aspirin and ibuprofen are generally safe before 30 weeks. Avoid aspirin when breastfeeding.
• Prochlorperazine has been used for pregnancy-related nausea for many years. Metoclopramide and domperidone are generally considered safe but are best avoided during the first trimester.
• For continuing frequent attacks, which warrant daily preventative treatment, propranolol has the best evidence of safety during pregnancy and breastfeeding
• If you have taken triptans and then find you are pregnant, don’t worry. However, continued use during pregnancy is not recommended without medical advice.
• If you are unlucky enough to continue with severe migraine attacks during your pregnancy, speak with your doctor. Other than the medications mentioned above, other options, such as nerve blocks or newer methods can be tried. Expert GP headache specialists at the National Migraine Centre can advise.

Listen to our Heads Up podcast episode 5 in series 1 to learn more about migraine in pregnancy.

Book an appointment with the experts: a consultation with a leading headache specialist, with an understanding of women’s health, migraine and pregnancy, could help you get on top of migraine. Book your consultation now.