Migraine Headache in pregnancy?

Headache and back pain are some prevalent complications in pregnancy and constitute up to 20% of a gynaecologist’s OPD. Most of the time gynaecologist relies on giving paracetamol tab as it seems to be safest for developing fetus. But Dr Anurag Aggarwal cautions that there is more to this headache and back pain business than just prescribing PCM every gynaecologist should keep in mind.

Dr Anurag Aggarwal, HOD of Emergency Medicine & Pain Medicine shares his expertise.

1. Plan and talk to your doctor before getting pregnant if you are on medications for headache

• First and foremost, if you are a migraineur and thinking of conceiving consult your doctor as many drugs are not safe for developing fetuses and must be shopped months before you are pregnant. For example, nonsteroidal anti-inflammatory drugs like ibuprofen are not safe in the first and third trimesters.
• Some of the migraine preventive therapies (medications taken regularly to prevent migraine attacks) are not safe in pregnancy and need to be discontinued months before conception such as topiramate, divalproex Sodium and the new CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab).

2. Migraines have a good chance of improving during pregnancy

There is good news as well for known migraine patients. There is a good chance of improving during pregnancy.

About 50% of women with migraine have an improvement by the first trimester.

About 87% of women with migraine have an improvement by the third trimester.

But in some patients, pregnancy hormones can cause a lack of sleep, nausea, change in eating and exercise habits, fatigue, and mood changes. All of these factors can contribute to headaches and migraines. Here are some tips for self-care that will ultimately help with the headaches:

• Stay hydrated
• Eat healthily
• Practice good sleep
• Incorporate exercise whenever possible
• Stretch your neck for a few minutes daily when in the bath or shower.

3. Distinguish between migraine and other secondary headaches

When treating a headache patient our first purpose is to distinguish a primary headache (when pain is the disease) from a secondary headache (when pain is a symptom of another disease). More strictly, this is the main concern for a pregnant woman suffering from this symptom. Three scenarios are possible:

1. She suffers from a primary headache and now she presents with her usual headache;
2. She does not suffer from a primary headache and she presents with her first severe headache during pregnancy
3. She suffers from a primary headache, but now the pain is different in quality, intensity or associated symptoms.

In the second and third scenarios, headache must be considered as a symptom of an underlying disease until an appropriate diagnostic evaluation has been performed.

The most common secondary headaches are

• cerebral venous thrombosis
• subarachnoid haemorrhage
• pituitary tumour
• choriocarcinoma
• eclampsia
• preeclampsia
• idiopathic intracranial hypertension
• reversible cerebral vasoconstriction syndrome (PRESS Syndrome)

There are certain red flag signs which will help us in deciding whether a headache is just any other primary headache or it’s a serious problem needing further evaluation.

Red Flags for Headaches in pregnancy

• Headache that peaks in severity in less than five minutes
• New headache type versus a worsening of a previous headache
• Change in previously stable headache pattern
• Headache that changes with posture (e.g. standing up)
• Headache awakening the pregnant
• Headache precipitated by physical activity or Valsalva manoeuvre (e.g. coughing, laughing,

Straining)

• Headache along with thrombophilia
• Neurological symptoms or signs
• Trauma
• Fever
• Seizures
• History of malignancy
• History of HIV or active infection
• Elevated blood pressure

In order to exclude a secondary headache additional study can be necessary:

• electroencephalography,
• ultrasound of the vessels of the head and neck,
• brain MRI and MR angiography with contrast ophthalmoscopy
• lumbar puncture

4. Safe Migraine medications in pregnancy

Once we have ruled out red flag signs and we are confident that we are dealing with migraine we should now know about the armamentarium of drugs which can be prescribed in pregnancy without harming the developing fetus.

During pregnancy and breastfeeding the preferred therapeutic strategy for the treatment of primary headaches should always be a non-pharmacological one but treatment should not be postponed as an undermanaged headache can lead to stress, sleep deprivation, depression and poor nutritional intake that in turn can have negative consequences for both mother and baby. Therefore, if non-pharmacological interventions seem inadequate, a well-considered choice should be made concerning the use of medication, taking into account all the benefits and possible risks.

The common medications used in pregnancy and postpartum for aborting an acute attack of headache or those utilized as prophylaxis for migraine or tension-type headache when the frequency of headache is four or more per month or at least eight headache days a month.

ACUTE MIGRAINE TREATMENT IN PREGNANCY

1. PCM 650-1000 mg with caffeine less than 200 mg/day
2. Naproxen, Ibuprofen, ketorolac before 30 weeks pregnancy. A modest increase in early pregnancy loss or some congenital anomalies if used in the first trimester but the evidence is weak. Use for less than 48 hrs.
3. After 30 weeks use should be avoided due to the risk of PDA closure, persistent pulmonary artery hypertension of newborns, oligohydramnios etc.
4. Triptans like sumatriptan 50-100 mg orally or rizatriptan 5-10 mg orally can be used in moderate to severe headaches not responding to other drugs.

ERGOTAMINE ABSOLUTELY CONTRAINDICATED IN PREGNANCY: risk of hypertonic uterine contractions.

Glucocorticoids – Glucocorticoids may be useful in intractable cases. Prednisone (20 mg orally four times daily for two days) or methylprednisolone (4 mg orally, 21 tablets over six days) are the preferred glucocorticoids because they are metabolized to inactive forms by the placenta and thus have minimal fetal effects, whereas dexamethasone and betamethasone are metabolically active in the fetus. Some older epidemiologic data suggest a possible association between first-trimester use of glucocorticoids and cleft lip and/or palate, while more recent data do not.

 MIGRAINE PROPHYLAXIS IN PREGNANCY:

First-line preventive therapies:

• Beta blockers such as propranolol, metoprolol, and atenolol are not teratogens, but fetal/neonatal effects from beta-blockade are possible with prolonged use and include mild fetal growth restriction and mild transient neonatal bradycardia, respiratory depression, hyperbilirubinemia, and/or hypoglycemia. Growth restriction may be more of an issue with atenolol than with other beta blockers. If possible, taper off beta blockers in TR3 and monitor newborns exposed in TR3
• Calcium channel blockers are commonly used for the treatment of hypertension and preterm labor without adverse fetal/pregnancy effects. An increase in congenital anomalies has not been reported in humans, although information is limited. Verapamil is the preferred agent because it is relatively safe and has good tolerability and ease of use.

Second-line preventive therapies:

• Low-dose antidepressants, such as the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine, or tricyclic antidepressants (TCA), may be considered in refractory patients, particularly those with suspected underlying chronic depressive illness or postpartum depression. Antidepressants have not been clearly associated with an increased risk of congenital anomalies but can have neonatal effects when taken in the third trimester.
• Gabapentin is an option for refractory patients. Some anticonvulsants, particularly valproate, are teratogenic and should be avoided

If you develop a new type of headache in pregnancy or have a headache with new symptoms such as vision changes, weakness, numbness, imbalance, or vertigo, please go to the emergency room for further evaluation as it is better to be on the safe side.

Remember, being pregnant does not mean you cannot treat your migraine attacks! It takes planning, patience and care from a doctor who specializes in prenatal headache management.

Please note: the content on this page is not intended to replace the medical advice of your doctor. Please always consult your doctor with any questions you might have about a medical condition. If you don’t have a doctor, find one here.